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Year : 2022  |  Volume : 12  |  Issue : 3  |  Page : 316-321

Attitudes of dental practitioners from Northern Morocco on the prescription of antibiotics during endodontic treatment: A survey

Department of Conservative Dentistry and Endodontics, The International University of Rabat, Rabat, Morocco

Date of Submission28-Mar-2022
Date of Decision30-Apr-2022
Date of Acceptance07-May-2022
Date of Web Publication1-Sep-2022

Correspondence Address:
Prof. Babacar Toure
The International University of Rabat, Technopolis- Rocade Rabat-Salé, 11 100, Sala Al Jadida
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sej.sej_61_22

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Introduction: Nowadays, antibiotics are not correctly used among some dental practitioners. Thus, the misuse of antibiotics could lead to antibiotic resistance in the long run. The aim of this study was to evaluate the prescribing attitudes of dental practitioners in Northern Morocco when treating pulpal and periapical pathologies.
Materials and Methods: This cross-sectional study involved 220 dental practitioners registered on the board of the National Council Order of Dentists of Morocco. A self-administered questionnaire, regarding the types of antibiotics used for endodontic treatment in healthy adult patients with endodontic pathological situations, was used and filled out via the E-mail addresses of practitioners chosen randomly. The data were analyzed with Jamovi (version 1.8.1). Quantitative variables were expressed as mean and standard deviation and qualitative variables as number and percentage. The Chi-square and the ANOVA tests were performed. The significance level was P < 0.05.
Results: Forty percentage of dental practitioners prescribed amoxicillin as a first-line therapy for a patient who does not have a penicillin allergy and for patients with a penicillin allergy; azithromycin was the drug of choice prescribed by 41.1% of practitioners. The duration of prescription was 6.5 days ± 0.7. No statistically significant difference was noted regarding the duration of the prescription, in relation to age, sex, specialization, and country of graduation (P > 0.05). The acute apical abscess represents the pathology for which most antibiotics are prescribed. Practitioners aged between 24 and 35 years prescribe more than the oldest practitioners (P = 0.04). Antibiotics were also prescribed for the management of pulpitis and chronic apical periodontitis. The lowest prescription rates were noted among practitioners specializing in or having benefited from endodontic training.
Conclusion: It emerges from this study that very few practitioners use antibiotics appropriately in treating pulpal and periapical pathologies. A real lack of knowledge has been noted with regard to indications, dosages, and duration.

Keywords: Antibiotic, apical periodontitis, dental practitioners, endodontic infection

How to cite this article:
Khaloufi O, Khalaf LH, Akerzoul N, Hassani FI, Toure B. Attitudes of dental practitioners from Northern Morocco on the prescription of antibiotics during endodontic treatment: A survey. Saudi Endod J 2022;12:316-21

How to cite this URL:
Khaloufi O, Khalaf LH, Akerzoul N, Hassani FI, Toure B. Attitudes of dental practitioners from Northern Morocco on the prescription of antibiotics during endodontic treatment: A survey. Saudi Endod J [serial online] 2022 [cited 2022 Oct 5];12:316-21. Available from: https://www.saudiendodj.com/text.asp?2022/12/3/316/354838

  Introduction Top

Endodontic treatment is based on the elimination of bacteria and their by-products through complete chemomechanical debridement of the root canal system, to reduce infection and to decrease the induced inflammation. In most cases, the patient's condition improves once the source of infection has been eliminated. In healthy individuals, bacteremia generated by endodontic treatments is rapidly eliminated and does not cause any complications.[1] In endodontics, antibiotics are used in addition to treatment in only certain particular pathological situations. According to the European Society of Endodontics,[2] the use of antibiotics during endodontic treatment requires that the infection be persistent or systemic in nature. Pain alone or the presence of swelling is not an indication for systemic antibiotic treatment. Thus, for their rational use, the American Association of Endodontists in 2017 and the European Society of Endodontics in 2018 organized a consensus conference to codify the use of antibiotics.[2],[3] Systemic antibiotic treatment is only indicated in the following pathological endodontic situations: acute apical abscess in medically compromised patients and with systemic involvement, progressive infections, and reimplantation of the avulsed permanent teeth.[2],[3],[4],[5],[6],[7]

Therefore, the prescription of antibiotics is not systematic during endodontic treatment. Thus, the misuse of antibiotics could lead to antibiotic resistance in the long run, the consequences of which are, among other things, an increase in the cost and duration of treatment, but also medical complications that can lead to therapeutic ineffectiveness. The Lancet Infectious Diseases Commission has published a series of articles on antibiotic resistance to encourage more careful use.[8],[9]

Consequently, the magnitude of the problem has led some authors to study the rational use of antibiotics during dental treatment. In endodontics, the prescription of antibiotics has been the subject of several studies. The results of the work already carried out in several countries show that very few practitioners, <1/3, use antibiotics efficiently in the face of pulp and periapical pathologies.[10],[11],[12]

They also revealed more precisely a real lack of knowledge with regard to the indications, doses, and durations of treatment. In Morocco, there are very little data on the use of antibiotics in endodontics. Due to the lack of knowledge on how some Moroccan dentists prescribe antibiotics during endodontic treatment, the objective of this study was to assess the level of knowledge and attitudes of dental practitioners on the use of antibiotics in the management of endodontic infections.

  Materials and Methods Top

This was a cross-sectional survey carried out between January and June 2021. The study was approved by the Ethics Committee from the University Dental Teaching Hospital of the International Faculty of Dental Medicine of Rabat, affiliated to the International University of Rabat (CUMD/FIMD 03/2021).

A self-administered questionnaire based on models from previous studies[13],[14],[15],[16],[17],[18],[19],[20],[21] was used. The questionnaire was sent via the E-mail addresses of the 220 dentists registered with the Dental North Board of Morocco and who were chosen randomly. The questionnaire was presented as a form. It has three parts: the first part related to the sociodemographic data of the practitioners (age, sex, country of graduation, seniority, and specialization in endodontics). The second part was related to the types of antibiotics used for endodontic treatment in healthy adult patients with or without penicillin allergy. The last part dealt with endodontic pathological situations where antibiotics are systematically prescribed. A reminder was done regularly every 15 days. Confidentiality and anonymity were respected; no information to identify participants was required.

The data were collected and analyzed with Jamovi software version 1.8.1 (Jamovi project, city and country: New castle, New South Wales, Australia). Quantitative variables were expressed as mean and standard deviation and qualitative variables as number and percentage. The Chi-square and ANOVA tests were performed to compare the data. The significance level was set at P < 0.05.

  Results Top

Only 121 (55%) practitioners (63 females and 58 males) responded. The average age was 37 ± 0.4 years with a minimum of 24 years and a maximum of 62 years. The distribution according to the age group showed that more than 75% of practitioners were <45-years-old, 51 practitioners aged between 25 and 35 years old, and 41 practitioners aged between 36 and 45-years-old. The majority of practitioners were graduates from Morocco (60%), 27% from Europe, and 13% from other African countries. Among the qualified practitioners in Europe, we noticed that 30% of graduates were from Spain, 27% from France, 22% from Russia, 18% from Belgium, and 3% from Romania. Concerning the specialization in endodontics, 33 practitioners declared having received postgraduate training in endodontics.

In the present study, the average duration of prescription was 6.5 days ± 0.7 with a minimum of 3 days and a maximum of 9 days. No statistically significant difference concerning the duration of prescription, in relation to age, sex, specialization, and country of graduation, was noted (P > 0.05)

In a patient without penicillin allergy

The majority of dentists (40%) selected 1 g of amoxicillin for treatment followed by amoxicillin associated with clavulanic acid (36.6%). Besides, there are 19.3% of dentists who prescribe a combination of metronidazole and spiramycin; and only 4.1% of them recommend the use of clindamycin and azithromycin.

In a patient with penicillin allergy

For these patients, azithromycin was the mostly used drug (41.1%), followed by the combination of metronidazole and spiramycin. On the other hand, among the least prescribed drugs was clindamycin 300 mg [Figure 1].
Figure 1: Types of antibiotics prescribed by dental practitioners for patients with medical allergies

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Endodontic pathologies in which antibiotics are prescribed

Based on the survey's answers, antibiotics were used by practitioners most of the time to treat pulpal and periapical pathologies. Furthermore, antibiotics were highly advised for acute apical abscess conditions (83.5%). However, these drugs were prescribed for irreversible pulpitis and other endodontic cases [Table 1].
Table 1: Clinical situations in which antibiotics were prescribed by the practitioners

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The prescription habits according to age groups showed that the younger practitioners (24–35 -years-old) prescribed antibiotics more frequently than the older ones (36–62-years-old). The difference was statistically significant (P = 0.04). They prescribed antibiotics for most of endodontic cases more than other age groups [Table 2] and [Table 3].
Table 2: Distribution of antibiotic prescriptions by the practitioners' age groups

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Table 3: Distribution of antibiotic prescriptions by country of graduation

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Moreover, practitioners who graduated from Morocco prescribed antibiotics oftentimes for the following conditions: acute irreversible pulpitis, pulp necrosis, pulp necrosis with sinus tract, and pulp necrosis with chronic apical periodontitis. Similarly, practitioners who graduated from other African countries advised prescribing antibiotics to treat: pain following endodontic treatment, pulp necrosis with chronic apical periodontitis, and for endodontic retreatment. On the other hand, European graduates prescribed antibiotics mostly to treat acute periodontitis and in the case of endodontic retreatment. Overall, Moroccan graduates prescribed more often antibiotics compared to graduates from other countries [Table 3]. The lowest prescription rates were noticed among specialized practitioners or those having received training in endodontics.

It was also noticed that the prescription practitioners among graduates of Morocco and other African countries were higher compared to those graduates of Europe (P = 0.03) [Table 2] and [Table 3].

Regarding pulp necrosis with chronic apical periodontitis, 80% of practitioners qualified from other African countries prescribed antibiotics compared to 45% of graduates from Morocco and Europe (P = 0.04). For endodontic retreatment, there was a high prescription among practitioners with degrees from Morocco and Europe (40%). Nevertheless, there was a low prescription by practitioners with degrees from other African countries (20%). Concerning apical surgery, there was a high prescription among practitioners with degrees from Morocco (53.8%) and Europe (33%) [Table 3].

  Discussion Top

In patients with no allergies, amoxicillin was the drug of choice among dentists.[6],[7] However, dentists prescribed azithromycin for patients with penicillin allergy. Furthermore, it is important to mention that Moroccan graduates frequently prescribed antibiotics for endodontic pathologies. Maybe this was due to the fact that the prices of antibiotics in Morocco are relatively cheaper compared to other countries, or the younger practitioners lack the experience in microbiology.

In the present study, amoxicillin associated with clavulanic acid takes the second favorite drug with 36.6% of practitioners prescribing it. Similar findings were reported in different countries.[6],[7],[13],[14],[15] This study was carried out for the first time in Northern Morocco. The response rate was within the average of other reports.[6],[7],[14],[15],[16],[17]

The results concerning drug prescription for early apical periodontitis were reported by different investigators.[16],[19],[20]

In the case of pulp pathologies dominated by inflammatory pain, the work of Hoskin has shown that antibiotics have no effect on the reduction of painful symptoms, which is managed by taking analgesics.[22]

Furthermore, in another corresponding study conducted in Saudi Arabia, the authors described that they had distributed 650 e-questionnaires to general dental practitioners in order to evaluate their knowledge and attitudes about patient care during endodontic treatment. The results showed that 77.7% of the dentists advised the patients to consume painkillers after root canal treatment just if they felt pain; only 19.3% of practitioners thought that antibiotics would reduce the ache following root canal treatment.[23]

For acute apical periodontitis, 38.8% of practitioners prescribed antibiotics. Among those practitioners, 80% were nonendodontic specialists. In a related study conducted in Kuwait, the researchers confirmed that 16% of dentists advised antibiotics for patients with severe dental pain and 62% recommended these drugs to treat acute apical abscesses. Furthermore, male practitioners gave more antibiotics compared to female dentists in order to decrease dental pain.[24] Unlike our study, the researchers did not find a major difference between the attitude of specialists and general dentists towards drug prescription.

Studies carried out by endodontic specialists in Brazil and the United States report lower rates of antibiotic consumption.[19],[25] In contrast, the results obtained from dentists in Spain show high rates of antibiotic prescriptions (59.8%).[6] However, in the present study, Moroccan dental practitioners prescribed less antibiotics for patients suffering from endodontic conditions compared to the dentists in Spain.

Chronic apical periodontitis, pulp necrosis, and chronic apical periodontitis with sinus tract are chronic pathologies whose treatment is based solely on root canal debridement without the use of antibiotics.[4] Nevertheless, in the present study, 27.3% of prescriptions were for chronic apical periodontitis with sinus tract and 13.2% for pulp necrosis. The reason behind this could be the fact that the dental practitioners feared an infection rising from these pathologies.

Amoxicillin is a medium-spectrum bactericidal β-lactam. It is also an effective anti-infective against Gram-negative bacteria. However, its action can be inhibited by bacteria producing β-lactamase. Therefore, in certain infections, a β-lactamase inhibitor such as clavulanic acid must be combined with β-lactams.[2] Hence, 36.6% of practitioners in this study prescribed the combination of these two molecules as a treatment (amoxicillin and clavulanic acid).

Azithromycin was the drug of choice for patients with penicillin allergy, followed by other drugs. Similar findings were reported by Al Khuzaei et al.[18] However, Bolfoni et al.[19] showed different results where clindamycin is the most prescribed antibiotic at 33%. The work of Rodriguez-Núñez et al.[26] also finds clindamycin as the first choice with 69% and azithromycin at 29.2%.

Metronidazole is an effective drug against bacteria with black pigmentation but less effective on aerobes or facultative anaerobes, which makes it more advisable to combine it with another antibiotic such as amoxicillin or spiramycin. Its association with amoxicillin should not be systematic but dictated by the evolution of the pathology. Metronidazole can be added to amoxicillin 2 to 3 days after the prescription of amoxicillin alone if there is no favorable evolution.

Acute oral infections evolve relatively quickly between 2 and 7 days if the infectious cause is eliminated. The average duration varies between 4.1 and 7.5 days in the literature. A short period of antibiotic treatment reduces the risk of toxicity and allergy induced by antibiotics but increases the risks of resistance.

In acute reversible, irreversible pulpitis and early apical periodontitis, where the pulp is still vital, there is no infection or signs or symptoms of systemic progression, so antibiotics are not indicated.[2],[4] Their use does not reduce pain in any way. However, in this study, one practitioner (0.8%) prescribed antibiotics for acute reversible pulpitis, and 4.1% for acute irreversible pulpitis.

In the situation of acute apical periodontitis, acute apical abscess or Chronic Apical Abscess without associated general signs after endodontic treatment, the host's defenses are sufficient to eliminate the infection.

However, if the general condition of the patient is compromised, or if there is a risk of spreading the infection, antibiotics may be prescribed. The majority of respondents prescribed antibiotics in these situations. This attitude is in accordance with the latest recommendations of endodontic scientific societies.[2]

In the present study, the survey's answers indicated that antibiotics are incorrectly used by practitioners. One can consider that this study was limited by several factors like: The questionnaire did not include questions about whether the practitioners had in their undergraduate studies courses about microbiology and biochemistry, not all the practitioners submitted their answers and the questionnaire did not include questions about the historical health of the patients.

In order to complete this study, further research is recommended to investigate the side effects of antibiotics after an endodontic treatment and bacterial.

  Conclusion Top

It appears from the present study that very few practitioners use antibiotics appropriately when dealing with pulpal and periapical pathologies. A real lack of knowledge among dental practitioners has been noticed with regard to indications, dosages, and durations. In view of the results of this study, it is important to recommend that practitioners comply with the standards and consensus in force concerning the prescription of antibiotics in endodontics.


The authors would like to present their sincere gratitude to the Vice-President of Research and Development of the International University of Rabat, Pr. Abdelaziz Benjouad.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Figure 1]

  [Table 1], [Table 2], [Table 3]


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