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174]
Original Article
Dental students compliance with antibiotic
prescribing guidelines for dental infections in children
Yee Chen Wong, Mandakini Mohan, Allan Pau
School of Dentistry, International Medical University, Kuala Lumpur, Malaysia
ABSTRACT
Context: To investigate the antibiotic prescribing
training received by dental students, clinical
experience in treating child patients, awareness
of antibiotic prescribing guidelines, preparedness
in antibiotic prescribing, and compliance
with antibiotic prescribing guidelines for the
management of dental infections in children.
Methods: This was a crosssectional study involving
final year dentals students from Malaysian
and Asian dental schools. A selfadministered
questionnaire consisting of five clinical case
scenarios was emailed to all final year students
at selected dental schools. Students responses
were compared for each clinical case scenario
with the prescribing guidelines of the American
Academy of Pediatric Dentistry and the American
Dental Association. Compliance in each scenario
was tested for association with their preparedness
in antibiotic prescribing, previous training on
antibiotic prescribing and awareness of antibiotic
prescribing guidelines using Chisquare test. Data
collected were analyzed using SPSS statistics
version 20. Results: A total of 108 completed
responses were received. About 74 (69%)
students were from Malaysian dental schools.
The compliance rate with prescribing guidelines
ranged from 15.7% to 43.5%. Those attending
Malaysian dental schools (47.3%) and those who
had treated child patient more often(46.3%) were
more likely(P<0.05) to be aware of the guidelines.
Those who had received antibiotic prescribing
training(21.3%) were more likely to think they were
well prepared in antibiotic prescribing(P<0.05).
Conclusions: Final year dental students had
low awareness and compliance with antibiotic
prescribing guidelines. Further research is needed
to investigate how compliance with the guidelines
may be enhanced.
KEYWORDS: Antibiotic prescribing,
education, dental students
348 2016 Journal of Indian Society of Pedodontics and Preventive Dentistry | Published by Wolters Kluwer - Medknow
Address for correspondence:
Prof. Allan Pau,
International Medical University, 126 Jalan Jalil Perkasa 19,
Bukit Jalil, Kuala Lumpur 57000, Malaysia.
Email:allan_pau@imu.edu.my
Access this article online
Quick response code Website:
www.jisppd.com
DOI:
10.4103/0970-4388.191415
PMID:
***
Introduction
The increasing incidence of antibiotic resistance has
been widely reported to pose an overwhelming threat
to worldwide public health[1,2] at the community,
country, and regional levels, resulting in harm to
individual patients.[3] Primary care patients prescribed
antibiotics for certain infections have been reported to
develop bacterial resistance to those antibiotics in the
month immediately after treatment, but may persist
for up to 12months.[4] This effect not only increases the
population carriage of organisms resistant to first line
antibiotics, but also creates the conditions for increased
use of second line antibiotics. Although clinicians in
general believe that antibiotic resistance is a public
This is an open access article distributed under the terms of the Creative
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allows others to remix, tweak, and build upon the work noncommercially,
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For reprints contact: reprints@medknow.com
How to cite this article: Wong YC, Mohan M, Pau A. Dental
students compliance with antibiotic prescribing guidelines for
dental dental infections in children. J Indian Soc Pedod Prev Dent
2016;34:348-53.
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Wong, etal.: Compliance with antibiotic prescribing guidelines

health problem, many believe that it is caused by
others.[5]
Factors contributing to the antibiotic resistance
phenomenon have been reported to include the
routine use of antibiotics in agriculture resulting
in potential direct infection with resistant bacteria
from an animal source[6] and overconsumption of
antibiotics in healthcare settings.[3] It is generally
acknowledged that the dentists have a role in helping
to reduce antimicrobial resistance development by
prescribing the correct drug, at the standard dosage
and appropriate regimen when necessary,[7,8] and
evidencebased guidance on sensible protocols for
antimicrobials prescribing has been set out.[9]
Systemic antibiotics are not routinely used in
dentistry as most dental and periodontal diseases
are best managed by surgical interventions and
oral hygiene measures, but overprescribing
practices by dentists is reportedly prevalent.[10]
Surveys of antibiotics prescribing among general
dental practitioners in the UK,[11,12] Australia,[13]
and Belgium,[14] among others, have concluded that
therapeutic prescribing of antibiotics varied widely
and was suboptimal. Overprescribing[15] and low
adherence to professional guidelines[16] in antibiotics
prescribing for dental infections in children have also
been reported.
Recent research has focused on preparing health
professions students for appropriate antibiotic
prescribing.[1720] A survey of 37 medical schools in
13 European countries has reported wide variations
in exposure of students to important principles of
prudent antibiotic use among countries and within
the same country.[21] Among dental vocational
practitioners in the UK, wide variations in the
therapeutic antibiotic regimens used have been
reported, with most not conforming to the guidelines

Table1: Clinical cases on antibiotic prescribing for dental infections in children

Yes No
Case 1: Imagine you are working in a private dental clinic. Ahealthy 9yearold child, who is a patient of the clinic, visits
during normal working hours with tooth pain in the lower right quadrant. On clinical examination, you notice a deep
carious lesion on the mandibular right primary second molar. Would you prescribe antibiotics for the following:
Pain only?
Pain and local swelling with no radiographic evidence of pathology?
Pain and local swelling with radiographic evidence of pathology?
Pain and facial swelling with radiographic evidence of pathology?
Case 2: Imagine you are working in a private dental clinic. Ahealthy 9yearold child, who is a patient of the clinic, visits
during normal working hours with tooth pain in the lower right quadrant and a fever of 38.3C. On clinical examination,
you notice a deep carious lesion on mandibular right primary second molar. Would you prescribe antibiotics for the
following:
Pain and fever?
Pain, fever and local swelling with no radiographic evidence of pathology?
Pain, fever and local swelling with radiographic evidence of pathology?
Pain, fever and facial swelling with radiographic evidence of pathology?
Case 3: Imagine you are working in a private dental clinic. Ahealthy 9yearold child, who is a patient of the clinic,
visits during normal working hours with tooth pain in the lower right quadrant. The child has no fever. On clinical
examination, you notice a deep carious lesion on the mandibular right primary second molar along with a draining
fistula. Would you prescribe antibiotics for the following:
Pain with a draining fistula only?
Pain, draining fistula and local swelling with no radiographic evidence of pathology?
Pain, draining fistula and local swelling with radiographic evidence of pathology?
Pain, draining fistula and facial swelling with radiographic evidence of pathology?
Case 4: Imagine you are working in a private dental clinic. The parent of a healthy 9yearold child, who is a patient of
the clinic, telephones you on a public holiday because the child has a chief complaint of tooth pain in the lower right
quadrant. Would you prescribe antibiotics for the following symptoms, if the parent can collect the prescription:
Pain only?
Pain and local swelling?
Pain and facial swelling?
I would see the child before prescribing antibiotics.
Case 5: Imagine you are working in a private dental clinic. The parent of a healthy 9yearold child, who is a patient of
the clinic, telephones you on a public holiday and reports that the child has pain on the lower right quadrant with some
warmness of the skin and some swelling that she noticed that morning. Would you prescribe antibiotics for the following
symptoms, if the parent can collect the prescription?
Pain, warmness of the skin and localized swelling?
Pain, warmness of the skin and facial swelling?
I would see the child before prescribing antibiotics.

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Wong, etal.: Compliance with antibiotic prescribing guidelines

available.[22] Some researchers have suggested that it is Table2: Distribution of subjects by sex, dental
crucial to develop appropriate curricula for teaching school, training in antibiotic prescribing, and
healthcare (pharmacy, dentistry, nursing, veterinary number of child patients treated(n=108)
medicine, and midwifery) undergraduate students
n(%)
about judicious antibiotic prescribing.[23,24] Little is
Sex
known about antibiotic prescribing among dental
Male 40(37.0)
students. This paper aims to report on antibiotic
prescribing training received by dental students, Female 68(63.0)
clinical experience in treating child patients, awareness School nationality
of antibiotic prescribing guidelines, preparedness in Malaysian 74(68.5)
antibiotic prescribing, and compliance with antibiotic NonMalaysian 34(31.5)
prescribing guidelines for the management of dental Training in antibiotic prescribing in the last 12
infections in children. months?
Yes 75(69.4)
No 33(30.6)
Methods Average number of child patients treated per week
Fewer than 1 41(38.0)
A crosssectional survey was conducted on final
1 or more 67(62.0)
year dental students using a selfadministered
questionnaire. Opportunistic sampling was carried out
to recruit students from a sample Malaysian and Asian Table3: Awareness of antibiotic prescribing
dental schools, selected through personal contacts. guidelines and association with sex, school
The survey was approved by the Institutional Review nationality, training in antibiotic prescribing and
Board. average number of child patients treated per week
Awareness of antibiotic prescribing
The survey instrument consisted of four main parts guidelines for treating dental
which included sample characteristics, clinical case infections in children
scenarios involving antibiotic prescribing decisions,[16] Yes n(%) No n(%) P value
perceptions on antibiotic resistance,[25] and confidence Sex
in prescribing antibiotics for dental infections.[26] Table1 Male 16(40.0) 24(60.0) 0.625
presents the five clinical cases on antibiotic prescribing Female 24(35.3) 44(64.7)
for dental infections in children. Four scenarios are School nationality
offered for case 14, and three for case 5. Students were
Malaysian 35(47.3) 39(52.7) 0.001
asked to indicate for each scenario whether they would
NonMalaysian 5(14.7) 29(85.3)
prescribe antibiotics or not. Students were deemed
Training in antibiotic
compliant with the guidelines if they answered all prescribing in the last 12
scenarios correctly in each case. They were considered months?
noncompliant if they answered wrongly in any one Yes 29(38.7) 46(61.3) 0.597
scenario. The proportion of participants who complied No 11(33.3) 22(66.7)
with the guidelines in each scenario was calculated. Average number of
child patients treated
Students were also asked for the number of child per week
patients they treated in a week, whether they had Fewer than 1 9(22.0) 32(78.0) 0.011
antibiotic training in the past 12 months, their 1 or more 31(46.3) 36(53.7)
awareness of any antibiotic prescribing guidelines and Total 40(37.0) 68(63.0)
how well prepared they felt in antibiotic prescribing
for children.
prescribing guidelines in each case were calculated.
An email was sent to selected dental schools in Compliance in each scenario was tested for association
Malaysia, Hong Kong, and Taiwan, seeking for approval with their preparedness in antibiotic prescribing,
to conduct the survey on their students. Following this, previous training on antibiotic prescribing, and
an email containing a link to the online questionnaire awareness of antibiotic prescribing guidelines using
was sent to the deans and student representatives of the Chisquare test.
the dental schools for them to cascade down to their
final year students from September to December 2014. Results
One further email was sent 1 month later to remind
those who had not responded. A total of 108 complete questionnaires were received
from final year dental students. Table 2 shows the
The data collected were analyzed using SPSS statistics distribution of students by sex, nationality of dental
version20 (IBM, Armonk, New York). The proportions school, training in antibiotic prescribing, and number
of participants who complied with antibiotic of child patients treated. Most were female(63.0%) and

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Wong, etal.: Compliance with antibiotic prescribing guidelines

from Malaysian dental schools(68.5%). Most reported Table4: Preparedness in antibiotic prescribing
having had training in antibiotic prescribing in the last for children and association with sex, school
12months(69.4%) and treated at least one child patient nationality, training in antibiotic prescribing and
per week(62.0%). average number of child patients treated per week
Do you think you have been
Only 37.0% students reported the awareness of prepared well in antibiotic
antibiotic prescribing guidelines for dental infections prescribing for children?
in children[Table3]. Those attending Malaysian dental Yes n(%) No n(%) P value
schools(47.3%) were more likely to report awareness
compared to those attending nonMalaysian dental Sex
schools(14.7%). Students who treated on average one Male 7(17.5) 33(82.5) 0.859
child patient or more per week(46.3%) were statistically Female 11(16.2) 57(83.8)
significantly more likely to be aware of antibiotic School nationality
prescribing guidelines compared to those who
treated fewer than one child patient per week(22.0%). Malaysian 15(20.3) 59(79.7) 0.138
Awareness of antibiotic guidelines was not associated NonMalaysian 3(8.8) 31(91.2)
with sex or antibiotic prescribing training. Training in antibiotic
prescribing in the last 12
months?
Only 16.7% of students thought that they were well
Yes 16(21.3) 59(78.7) 0.050
prepared for antibiotic prescribing for children
No 2(6.1) 31(93.9)
[Table 4]. Students who had received antibiotic
Average number of child
prescribing training (21.3%) were statistically patients treated per week
significantly more likely to think they were well Fewer than 1 3(7.3) 38(92.7) 0.041
prepared in antibiotic prescribing compared to those 1 or more 15(22.4) 52(77.6)
who had not received training (6.1%). Those who
Total 18(16.7) 90(83.3)
treated on average one child patient or more per
week (22.4%) were statistically significantly more
likely to be aware of antibiotic prescribing guidelines
compared to those who treated fewer than one child Table5: Compliance rates to antibiotic guidelines
patient per week (7.3%). Preparedness in antibiotic for each of the clinical cases
prescribing for children was not associated with sex or Noncompliance with Compliance with
school nationality. clinical guidelines clinical guidelines
n(%) n(%)
The compliance rate with prescribing guidelines in Case 1 61(56.5) 47(43.5)
each of the clinical case ranged from 15.7% to 43.5% Case 2 91(84.3) 17(15.7)
[Table5]. For case 1, 43.5% would prescribe antibiotics Case 3 71(65.7) 37(34.3)
only for pain and facial swelling with radiographic Case 4 77(71.3) 31(28.7)
evidence of pathology, which is consistent with the Case 5 80(74.1) 28(25.9)
AAPD guidelines. For case 2, when fever was added to
the scenario, the compliance rate was 15.7%. For case 3,
when fever was absent, but draining fistula was added Discussion
to the signs and symptoms, the compliance was 34.3%.
For cases 4 and 5, which were nonworking day cases, the This study investigated the prevalence dental students
compliance rates were 28.7% and 25.9%, respectively. training in antibiotic prescribing, clinical experience
in treating child patients, awareness of antibiotic
For most of the cases, compliance with antibiotic prescribing guidelines for dental infections in children,
guidelines did not appear to be associated with school and preparedness in antibiotic prescribing, and their
nationality, training in antibiotic prescribing in the last association with compliance with existing guidelines.
12months, child patients treated per week, awareness The key findings were that most students had received
of antibiotic prescribing guidelines, or preparedness training on antibiotic prescribing and had treated
in antibiotic prescribing. The exceptions were for one or more child patients per week, but most were
case 2, in which students who had received antibiotic not aware of any guidelines on antibiotic prescribing
prescribing training (21.3%) were more likely to be or felt well prepared in antibiotic prescribing.
compliant when compared to students who had Compliance with guidelines was generally low and
not(3.0%). For nonworking day case 5, students who was not associated with training, clinical experience,
treated one or more child patient per week (52.2%) awareness, or preparedness.
were more likely to be compliant when compared to
students who treated fewer than one child patient per Only a third of participants in the present study
week(31.7%). reported the awareness of any antibiotic prescribing

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Wong, etal.: Compliance with antibiotic prescribing guidelines
guidelines, with variations observed between
countries and those with different degrees of clinical
experience in treating child patients. Awareness was
surprisingly not associated with training in antibiotic
prescribing. Health professions students knowledge
on antibiotic prescribing has consistently been reported
to be poor[21,23,27] and most felt that more learning was
needed.[22,24,28]
The majority of the students in the present study did
not feel well prepared in antibiotic prescribing for
children. Those who had received training and those
with more clinical experience were more likely to feel
well prepared. Consistent with the literature, lack of
prepared has been reported for medical students in the
USA[27] and lack of confidence for medical students in
Europe.[28]
Compliance with antibiotic guidelines in the case
scenarios presented in the present study was low.
Similar lack of concordance between guidelines and
the antibiotic prescribing practices of dentists has
been reported.[16] Compliance did not appear to be
associated with training in antibiotic prescribing,
clinical experience, awareness of guidelines or
preparedness for practice, although in two of the
case scenarios training and clinical experience were
associated with compliance. Dissonance between
knowledge and behaviors, however, may be explained
by contextual influences decisions, such as patient and
system factors, diagnostic uncertainty, and the habits
of, and relationship with, supervisors.[29]
The findings of the present study should be viewed in
the context of its limitations. Recruiting students to the
study was challenging, even though the survey was
approved and supported by the deans of dental schools
that were approached. Consequently, the sample size
was small. However, within these limitations, the
findings are consistent with other studies and highlight
the need to improve education in antibiotic prescribing
around the world, including Asia. Dissemination of
antibiotic prescribing guidelines is also important,
including the treatment of dental infections in children.
Antibiotic prescribing education may be in the form
of lectures, workshops, informal education in clinical
practice, and selfdirected learning. Besides clinical
education, there are a number of intervention programs,
such as patient education, delayed prescriptions, audit
and feedback, clinician reminder and decision support
system, and financial and regulatory incentives or
disincentives that may be implemented to promote
judicious antibiotic prescribing.[23] The use of delayed
prescriptions for infections for which antibiotics are not
immediately indicated effectively reduce antibiotic use by
patients and does not result in excess morbidity.[30] Such
education will instill greater selfconfidence in reducing
antibiotic prescribing, and at least some change in
consultation style and antibiotic prescribing behavior.[31]
352 Journal of Indian Society of Pedodontics and Preventive Dentistry | Oct-Dec 2016 | Vol 34 | Issue 4 |
Conclusion
Final year dental students are future dentists who
will be serving the community. Yet, the findings of
this survey suggest that there was low awareness
of professional guidelines and compliance with the
guidelines was low. Much more coordinated efforts
within a country and between countries are needed
to educate dental students in judicious antibiotic
prescribing, and to better prepare them for their
practice as future dentists.
Financial support and sponsorship
This study was sponsored by an IMU internal grant
(BDS I1/2011(03)2014).
Conflicts of interest
There are no conflicts of interest.
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