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Antibiotic prophylaxis in general oral health care: the perspective of decision making
Malmö högskola, Faculty of Odontology (OD).
2009 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [sv]

I Sverige ger läkemedelskommittéerna i landstingen ut rekommendationer för att stödja optimal användning av läkemedel till patienter. Rekommendationerna inkluderar råd om när antibiotika bör användas i förebyggande syfte (antibiotikaprofylax) i tandvården. Detta kan vara aktuellt i samband med tandingrepp för att förebygga infektioner hos patienter med specifika medicinska tillstånd, t.ex. hjärtklaffsprotes, diabetes eller njurtransplantat. Vid användning av antibiotika finns risker för oönskade reaktioner hos patienten i form av hudutslag, diarréer men även livshotande allergiska reaktioner. På samhällsnivå finns risk att bakterier blir resistenta mot antibiotika. Med bakgrund av detta bör det finnas en strävan efter att minimera användning av antibiotika.I denna avhandling har syftet varit att 1) utvärdera de vetenskapliga bevisen i litteraturen för att använda antibiotikaprofylax i tandvården, samt överensstämmelsen mellan rekommendationer från läkemedelskommittéerna och vetenskapliga bevis, 2) studera tandläkares användning av antibiotikaprofylax och hur väl de följer rekommendationer, 3) studera tandläkares säkerhet i sina beslut om att ge antibiotikaprofylax och 4) studera tandläkares riskbedömningar i sina beslut om att ge antibiotikaprofylax.Metoden för det första syftet var en systematisk litteraturöversikt av vetenskapliga studier. Det systematiska tillvägagångssättet inkluderade definierade inklusions- och exklusionskriterier för studierna, på förhand definierade granskningsprotokoll av studiernas kvalitet, samt en övergripande kvalitetsbedömning av de vetenskapliga bevisen. För resterande syften genomfördes en enkätundersökning. Enkäten innehöll åtta simulerade patientfall med olika medicinska tillstånd, inklusive tillstånd där antibiotikaprofylax bör ges enligt rekommendationer och tillstånd där antibiotika inte bör ges. Enkäten skickades till 200 slumpmässigt utvalda allmäntandläkare i två landsting i Sverige, Skåne och Örebro läns landsting. Svarsfrekvensen var 51% (101/200). Tandläkarna fick svara på om de skulle ge antibiotikaprofylax, hur säkra de var i sina beslut och hur de bedömde risken för komplikationer om antibiotikaprofylax inte användes.Resultaten kan sammanfattas i följande punkter:• Det saknas vetenskapliga bevis som stödjer användning av antibiotikaprofylax• Rekommendationerna inkluderade flera medicinska tillstånd där antibiotikaprofylax bör ges• Det fanns en stor variation i tandläkarnas sätt att använda antibiotikaprofylax• Tandläkarna följde rekommendationer i liten omfattning• Tandläkarna hade hög säkerhet i sina beslut, oavsett om de gav antibiotikaprofylax eller ej och oavsett om deras beslut var i enlighet med rekommendationer eller ej• Tandläkarnas riskbedömningar var rationella men byggde på bristande kunskap, dvs. de gav antibiotikaprofylax på ett konsekvent sätt utifrån sina riskbedömningar, men riskbedömningarna var överskattade och felaktiga jämfört med de verkliga riskerna.Slutsatser:Det saknas vetenskapliga bevis för att använda antibiotikaprofylax i tandvården. Trots det inkluderar rekommendationerna en mängd medicinska tillstånd. För att minimera användning av antibiotika, bör rekommendationer stramas upp för att vara mer i överensstämmelse med vetenskapliga bevis. Nästa problem var tandläkarnas stora variation i sina beslut och att de endast i liten omfattning följde rekommendationer. Detta visar att besluten inte är optimala och att de bör förbättras. Potentiella hinder för en sådan förbättring kan vara att tandläkarna var väldigt säkra i sina beslut och att de gjorde överskattade och felaktiga riskbedömningar. Tidigare forskning visar att det är mycket svårt att implementera rekommendationer för att förändra beteende hos sjukvårdspersonal. Troligen skulle det innebära stora utmaningar i att lyckas förändra tandläkares sätt att använda antibiotikaprofylax.

Abstract [en]

In Sweden, pharmaceutical committees in the counties devote resources to recommendations aimed at supporting optimal medication for patients. These recommendations include oral health care, with advice on when to administer antibiotic prophylaxis in connection with dental procedures to prevent infectious complications in patients with specific medical conditions. There has been much discussion about the use of antibiotic prophylaxis in oral health care and the evidence that the recommendations are based upon is questionned. When using antibiotics, there exist risk of adverse events such as skin rashes, diarrhoea or life-threatening anaphylactic reactions as well as the risk of developing resistant bacterial strains. With this background the use of antibiotics should be minimised.The objectives of this thesis were to: 1) evaluate the evidence in the literature for the use of antibiotic prophylaxis in oral health care, and the agreement between Swedish recommendations and evidence, 2) examine general dental practitioners’ (GDPs’) administration strategies of antibiotic prophylaxis, and the agreement between GDPs’ administration strategies and recommendations, 3) examine GDPs’ confidence in their decisions on administration of antibiotic prophylaxis and 4) examine GDPs’ assessment of risk in their decisions on administration of antibiotic prophylaxis. The method for the first objective was a systematic literature review of scientific studies. The systematic approach included defined inclusion and exclusion criteria, pre-defined protocols for data extraction and quality assessment of studies, as well as an overall evaluation of the quality of evidence. For the other objectives a questionnaire study was conducted. The questionnaire comprised eight simulated cases of patients with different medical conditions. We included conditions for which antibiotic prophylaxis should be administered when performing dental procedures according to recommendations, and conditions for which antibiotic prophylaxis should not be administered. For each medical condition three different dental procedures (scaling, tooth removal and root canal treatment) were presented. These dental procedures could cause bleeding to various degrees. The questionnaire was sent to 200 randomly selected GDPs in Skåne and Örebro counties. The response rate was 51% (101/200). The GDPs were asked to answer whether they would administer antibiotic prophylaxis, how confident they were in their decisions and their assessment of the risk of complications if antibiotic prophylaxis was not administered. The results are summarised in the following most important key points:• According to evidence, there exist no medical condition for which antibiotic prophylaxis should be used• Swedish recommendations include several medical conditions for which antibiotic prophylaxis should be used• There was a large variation in GDPs’ administration strategies• Agreement between GDPs’ administration strategies and recommendations was low• GDPs were highly confident about their decisions, regardless of whether they administered antibiotic prophylaxis or not, and regardless of whether their decisions were according to recommendations or not• GDPs’ risk assessments were rational but uninformed, i.e. they administered antibiotic prophylaxis in a manner that was consistent with their risk assessments, but their risk assessments were overestimated and inaccurate in terms of the actual risks. In conclusion: According to evidence, there exist no medical condition for which antibiotic prophylaxis should be used. Still, Swedish recommendations include several medical conditions for which antibiotic prophylaxis should be used. To avoid the risk of adverse events and of developing resistant bacterial strains, Swedish recommendations should be more evidence-based. GDPs varied greatly in their administration strategies and their decisions exhibited low agreement with recommendations. This shows that the decisions of GDPs are less than optimal and should be improved. The high confidence that GDPs expressed in their decisions, along with their overestimated and inaccurate risk assessments, might serve as potential barriers to behavioural modifications. Previous research suggest that it is very difficult to implement recommendations to change the behaviour of clinicians. Current knowledge about successful implementation strategies is limited. Changing GDPs’ decisions about administration of antibiotic prophylaxis is likely to be very difficult.

Place, publisher, year, edition, pages
Malmö University , 2009. , p. 122
Series
Doctoral Dissertation in Odontology
Keywords [en]
Antibiotic prophylaxis, Decision making
National Category
Dentistry
Identifiers
URN: urn:nbn:se:mau:diva-7708Local ID: 8171ISBN: 91-7104-305-5 (print)OAI: oai:DiVA.org:mau-7708DiVA, id: diva2:1404648
Note

Paper I and IV in dissertation as manuscript. 

Available from: 2020-02-28 Created: 2020-02-28 Last updated: 2024-03-01Bibliographically approved
List of papers
1. Antibiotic prophylaxis in oral healthcare - the agreement between Swedish recommendations and evidence
Open this publication in new window or tab >>Antibiotic prophylaxis in oral healthcare - the agreement between Swedish recommendations and evidence
2010 (English)In: British Dental Journal, ISSN 0007-0610, E-ISSN 1476-5373, Vol. 208, no 3, article id E5Article in journal (Refereed)
Abstract [en]

BACKGROUND: Almost all (17/20) Swedish counties have pharmaceutical committees that establish recommendations for the use of antibiotic prophylaxis in oral healthcare.Objective To evaluate the evidence for the use of antibiotic prophylaxis in oral healthcare and the agreement between Swedish recommendations and evidence. MATERIAL AND METHODS: We conducted a systematic literature search in PubMed and the Cochrane Controlled Trials Register. The MeSH terms 'antibiotic prophylaxis' and 'dentistry' were used in the database search. Abstracts were reviewed according to specific inclusion and exclusion criteria. A total of 186 articles were read in full text by the four authors independently. Data extraction and interpretation of data was carried out using a pre-defined protocol. In the end, one case-control study was included for evaluation of evidence. RESULTS: The case-control study included patients with specific cardiac conditions. The study reported a 49% protective efficacy (odds ratio: 0.51) of antibiotic prophylaxis for first-time episodes of endocarditis within 30 days of procedure. This result was not statistically significant. The quality of the evidence was low. No studies were evaluated on patients with other medical conditions. The recommendations included several cardiac and other medical conditions for which there is a lack of evidence or no evidence to support the use of antibiotic prophylaxis. CONCLUSIONS: There is a lack of evidence to support the use of antibiotic prophylaxis. To avoid the risk of adverse events from antibiotics and the risk of developing resistant bacterial strains, the use of antibiotic prophylaxis should be minimised and recommendations in Sweden should be revised to be more evidence-based.

National Category
Dentistry
Identifiers
urn:nbn:se:mau:diva-6372 (URN)10.1038/sj.bdj.2010.107 (DOI)000274430200017 ()20134479 (PubMedID)2-s2.0-77149153694 (Scopus ID)10646 (Local ID)10646 (Archive number)10646 (OAI)
Available from: 2020-02-28 Created: 2020-02-28 Last updated: 2024-02-05Bibliographically approved
2. Antibiotic Prophylaxis in Oral Health Care: Administration Strategies of General Dental Practitioners
Open this publication in new window or tab >>Antibiotic Prophylaxis in Oral Health Care: Administration Strategies of General Dental Practitioners
Show others...
2005 (English)In: Acta Odontologica Scandinavica, ISSN 0001-6357, E-ISSN 1502-3850, Vol. 63, no 6, p. 321-329Article in journal (Refereed)
Abstract [en]

Objective. To examine the strategies that general dental practitioners (GDPs) use to administer antibiotic prophylaxis and to study the agreement between the administration strategies of GDPs and local recommendations. Methods. Postal questionnaires in combination with telephone interviews were used. Two hundred GDPs in two Swedish counties, Skåne and Örebro, were asked to participate. The response rate was 51 % (n=101). The GDPs were presented with eight simulated cases of patients with different medical conditions for which antibiotic prophylaxis might be considered necessary when performing dental procedures (scaling, tooth removal, root canal treatment). The administration strategies of the GDPs were compared with local recommendations. Results. In general, the variation in the administration strategies of the GDPs was large. For two medical condi-tions, type 1 diabetes that was not well controlled and hip prosthesis, significantly more GDPs in Skåne than in Örebro administered antibiotic prophylaxis for tooth removal. Agreement between the administration strategies of the GDPs and local recommendations was low. Differences between the two counties were non-significant. Furthermore, within Örebro, GDPs who did not have formal access to local recommendations did not differ in their administration strategies from those who did. The choice of substance was seldom in agreement with the substance recommended, while the majority followed the recommended duration of treatment. Conclusion. Although recommendations existed, their impact appeared to be limited. This is significant, since the implementation of recommendations is crucial in making clinical practice more effective and in promoting the health of patients.

National Category
Dentistry
Identifiers
urn:nbn:se:mau:diva-15752 (URN)10.1080/00016350500206660 (DOI)000233536600002 ()16512104 (PubMedID)2-s2.0-32644432779 (Scopus ID)3042 (Local ID)3042 (Archive number)3042 (OAI)
Available from: 2020-03-30 Created: 2020-03-30 Last updated: 2024-02-05Bibliographically approved
3. How confident are general dental practitioners in their decision to administer antibiotic prophylaxis?
Open this publication in new window or tab >>How confident are general dental practitioners in their decision to administer antibiotic prophylaxis?
2008 (English)In: BMC Medical Informatics and Decision Making, E-ISSN 1472-6947, Vol. 8, article id 57Article in journal (Refereed)
Abstract [en]

Background: Common dental procedures induce bacteremia. To prevent infectious complications from bacteremia in patients with specific medical conditions, antibiotic prophylaxis is considered. Recommendations are often unclear and ambiguous. In a previous study we reported wide variations in general dental practitioners’ (GDPs’) administrations of antibiotic prophylaxis. We hypothesized that within such a conflicting clinical area, decisions are made with a high level of personal uncertainty. This study examined GDPs’ confidence in their decisions and analyzed the extent to which case-related factors might explain individual variations in confidence. Methods: Postal questionnaires in combination with telephone interviews were used. The response rate was 51% (101/200). There were no significant differences between respondents and non-respondents regarding sex, age, or place of work. The GDPs were presented to patient cases of different medical conditions, where some should receive antibiotic prophylaxis according to recommendations when performing dental procedures that could cause gingival bleeding. The GDPs assessed on visual analogue scales how confident they were in their decisions. The extent to which case-related factors, medical condition and dental procedure, could explain individual variation in confidence was analyzed. Results: Overall the GDPs exhibited high confidence in their decisions regardless of whether they administered antibiotic prophylaxis or not, or whether their decisions were in accordance with recommendations or not. The case-related factors could explain between 30–100% of the individual variation in GDPs’ confidence. For 46%, the medical condition significantly explained the individual variation in confidence. However, for most of these GDPs, lower confidence was not presented for conditions where recommendations are unclear and higher confidence was not presented for conditions where recommendations are more clear. For 8% the dental procedure significantly explained the variation, although all procedures could cause bacteremia. For 46% neither the medical condition nor the dental procedure could significantly explain the individual variation in confidence. Conclusions: The GDPs presented high confidence in their decisions, and the majority of GDPs did not present what could be considered a justified varied level of confidence according to the clarity of recommendations. Clinicians who are overconfident in their decisions may be less susceptible to modifications of their behavior to more evidence-based strategies.

Place, publisher, year, edition, pages
BioMed Central, 2008
Keywords
antibiotic prophylaxis, dentistry, decision making, confidence
National Category
Dentistry
Identifiers
urn:nbn:se:mau:diva-6209 (URN)10.1186/1472-6947-8-57 (DOI)000263126100001 ()19061525 (PubMedID)2-s2.0-60849089363 (Scopus ID)8106 (Local ID)8106 (Archive number)8106 (OAI)
Available from: 2020-02-28 Created: 2020-02-28 Last updated: 2024-02-05Bibliographically approved
4. Risk Judgment by General Dental Practitioners: Rational but Uninformed
Open this publication in new window or tab >>Risk Judgment by General Dental Practitioners: Rational but Uninformed
2010 (English)In: Biomedical Informatics Insights, E-ISSN 1178-2226, Vol. 2010, no 3, p. 11-17Article in journal (Refereed) Published
Abstract [en]

Background: Decisions by dentists to administer antibiotic prophylaxis to prevent infectious complications in patients involves professional risk assessment. While recommendations for rational use have been published, several studies have shown that dentists have low adherence to these recommendations. Objective: To examine general dental practitioners’ (GDPs’) assessments of the risk of complications if not administering antibiotic prophylaxis in connection with dental procedures in patients with specific medical conditions. Methods: Postal questionnaires in combination with telephone interviews. Risk assessments were made using visual analogue scales (VAS), where zero represented “insignificant risk” and 100 represented a “very significant risk”. Results: Response rate: 51%. The mean risk assessments were higher for GDPs who administered antibiotics (mean = 54, SD = 23, range 26–72 mm on the VAS) than those who did not (mean = 14, SD = 12, range 7–31 mm) (P < 0.05). Generally, GDPs made higher risk assessments for patients with medical conditions that are included in recommendations than those with conditions that are not included. Overall, risk assessments were higher for tooth removal than for scaling or root canal treatment, even though the risk assessments should be considered equal for these interventions. Conclusions: GDPs’ risk assessments were rational but uninformed. They administered antibiotics in a manner that was consistent with their risk assessments. Their risk assessments, however, were overestimated. Inaccurate judgments of risk should not be expected to disappear in the presence of new information. To achieve change, clinicians must be motivated to improve behaviour and an evidence- based implementation strategy is required.

Place, publisher, year, edition, pages
Libertas Academica, 2010
National Category
Dentistry
Identifiers
urn:nbn:se:mau:diva-7124 (URN)10.4137/bii.s4067 (DOI)000215018200002 ()27458329 (PubMedID)10650 (Local ID)10650 (Archive number)10650 (OAI)
Available from: 2020-02-28 Created: 2020-02-28 Last updated: 2024-05-23Bibliographically approved

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