Antibiotic Prescribing Practices in Endodontic Infections: A Survey of Dentists in Serbia

Abstract

The study goal was to provide an overview of antibiotic prescribing practices of Serbian dentists when treating endodontic infections and to disseminate the current ESE (European Society of Endodontology) recommendations to the study participants. A link to an online questionnaire was sent to 628 Serbian dentists whose email addresses were publicly available on the Internet, 158 of whom responded to the survey, resulting in a 25.16% response rate. The significance of possible associations was assessed via the Chi-squared test and Cramer’s V measure of association, with p < 0.05 considered as statistically significant. According to the study findings, 55.7% of respondents prescribed a 5-day antibiotic course. Moreover, Amoxicillin 500 mg was the first-choice antibiotic for 55.1% of the respondents, followed by Clindamycin 600 mg (18.4%). For patients allergic to penicillin, 61.4% of respondents prescribed Clindamycin. Statistically significant differences emerged only in relation to acute apical abscess with systemic involvement, whereby dentists aged 46–55 were least likely to prescribe antibiotics in these clinical situations (p = 0.04). Analyses further revealed that recommendations for safe antibiotic prescribing practices were not always followed, as in certain cases, patients were given antibiotics even when this was not indicated. These findings highlight the need for additional education on responsible antibiotic use to prevent bacterial resistance.

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antibiotics
Article
Antibiotic Prescribing Practices in Endodontic Infections:
A Survey of Dentists in Serbia
Milan Drobac * , Katarina Otasevic, Bojana Ramic, Milica Cvjeticanin, Igor Stojanac and Ljubomir Petrovic


Citation: Drobac, M.; Otasevic, K.;
Ramic, B.; Cvjeticanin, M.; Stojanac, I.;
Petrovic, L. Antibiotic Prescribing
Practices in Endodontic Infections: A
Survey of Dentists in Serbia.
Antibiotics 2021,10, 67. https://
doi.org/10.3390/antibiotics10010067
Received: 17 December 2020
Accepted: 7 January 2021
Published: 12 January 2021
Publisher’s Note: MDPI stays neu-
tral with regard to jurisdictional clai-
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nal affiliations.
Copyright: © 2021 by the authors. Li-
censee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and con-
ditions of the Creative Commons At-
tribution (CC BY) license (https://
creativecommons.org/licenses/by/
4.0/).
Department of Dental Medicine, Faculty of Medicine, University of Novi Sad, Hajduk Veljkova 12,
21000 Novi Sad, Serbia; katarina.otasevic@mf.uns.ac.rs (K.O.); bojana.ramic@mf.uns.ac.rs (B.R.);
milica.premovic@mf.uns.ac.rs (M.C.); igor.stojanac@mf.uns.ac.rs (I.S.); petns@uns.ac.rs (L.P.)
*Correspondence: milan.drobac@mf.uns.ac.rs; Tel.: +381-21612222
Abstract:
The study goal was to provide an overview of antibiotic prescribing practices of Serbian
dentists when treating endodontic infections and to disseminate the current ESE (European Society
of Endodontology) recommendations to the study participants. A link to an online questionnaire was
sent to 628 Serbian dentists whose email addresses were publicly available on the Internet, 158 of
whom responded to the survey, resulting in a 25.16% response rate. The significance of possible
associations was assessed via the Chi-squared test and Cramer’s V measure of association, with
p< 0.05
considered as statistically significant. According to the study findings, 55.7% of respondents
prescribed a 5-day antibiotic course. Moreover, Amoxicillin 500 mg was the first-choice antibiotic for
55.1% of the respondents, followed by Clindamycin 600 mg (18.4%). For patients allergic to penicillin,
61.4% of respondents prescribed Clindamycin. Statistically significant differences emerged only in
relation to acute apical abscess with systemic involvement, whereby dentists aged 46–55 were least
likely to prescribe antibiotics in these clinical situations (p= 0.04). Analyses further revealed that
recommendations for safe antibiotic prescribing practices were not always followed, as in certain
cases, patients were given antibiotics even when this was not indicated. These findings highlight the
need for additional education on responsible antibiotic use to prevent bacterial resistance.
Keywords: antibiotic prescription; cross-sectional study; endodontic infections; Serbia
1. Introduction
Excessive antibiotic use and consequent bacterial resistance are significant global
problems [
1
]. Given that dentists prescribe approximately 10% of the antibiotics distributed
in primary care, it is essential that they do so responsibly [
2
]. In order to prevent antibiotic
overuse, in 2018, the European Society of Endodontology (ESE) issued the most recent rec-
ommendations for prescribing practices related to endodontic infections [
3
] and suggested
that their members forward this information to dentists in their respective countries.
It is well known that antibiotics are ineffective in reducing pain or swelling of odonto-
genic origin in the absence of systemic signs of infection [
2
]. An ample body of empirical
evidence indicates that antibiotics should only be prescribed to patients exhibiting systemic
signs of infection or as a part of therapy offered to immunocompromised individuals [
4
–
6
].
In particular, they are not indicated for irreversible pulpitis, pulp necrosis, symptomatic
apical periodontitis, chronic apical abscesses, acute apical abscesses without systemic
involvement, tooth fractures, and concussions. These guidelines should be followed by
dentists to reduce antibiotic overuse [
1
,
7
,
8
]. According to the World Health Organization
(WHO) report published in 2014, inappropriate usage of antibiotics can lead to antimi-
crobial resistance (AMR) [
9
]. Although AMR is not a new phenomenon, it has recently
become a serious issue as, under selective pressure due to the overuse of antibiotics,
resistant clones are favored and the emergence and spread of resistance has rapidly ac-
celerated [
9
]. Bacteria may be innately resistant to certain antibiotics, but may acquire
antibiotic resistance through mutations in chromosomal genes and through horizontal
Antibiotics 2021,10, 67. https://doi.org/10.3390/antibiotics10010067 https://www.mdpi.com/journal/antibiotics

Antibiotics 2021,10, 67 2 of 11
gene transfer [
9
]. Thus, AMR significantly contributes to morbidity and mortality rates.
For example, Prestinaci et al. estimated that about 400,000 infections and 25,000 deaths in
Europe were caused by the most multi-drug resistant bacteria [
10
]. Given that in 2017, a
4.6% prevalence of intrahospital infections was reported by the Institute of Public Health
of Serbia, it is essential to adopt more prudent antibiotic prescribing practices to avoid
bacterial drug resistance [
11
]. A high level of resistance to all antibiotics tested, similar
to that in the countries of southern and eastern Europe, has been observed in all tested
bacterial species in the Republic of Serbia. The high level of resistance to carbapenems
is of particular concern as these antibiotics are considered the last line of defense against
antibiotic-resistant bacteria [
12
]. As a part of the implementation of the European Strategic
Plan for Antibiotic Resistance, in 2017, the WHO for Europe established the Antimicrobial
Medicines Consumption Network (AMC) to monitor the consumption of antimicrobial
drugs among the AMC group members. According to the total consumption, the Republic
of Serbia was in fourth place with 29.47 defined daily doses (DDDs) per 1000 individuals
in 2014 [
13
]. This motivated the present study, as a part of which an overview of antibiotic
prescribing practices for endodontic infections was conducted with the view of sharing
the findings, along with the current ESE recommendations, with the dentists practicing
in Serbia.
2. Materials and Methods
This research was approved by the Committee of Ethics of the Faculty of Medicine,
University of Novi Sad (01-39/360/1, 11 December 2018). To obtain the data necessary
for meeting the study objectives, an online questionnaire was developed and was made
available to Serbian dentists via the following link: https://docs.google.com/forms/d/
14J0BNQ6UWILc1cQCQoP4FSqIDmBLJ_Dd6xglALKfm-0. As the Law on Personal Data
Protection (Legal Acts Republic of Serbia, number 87/2018) prohibits use of the Serbian
Dental Chamber records for identifying study participants, only dentists whose email
addresses were publicly available on the Internet were contacted and invited to take part
in the survey. This resulted in an initial sample of 628 potential respondents. The survey
items were adapted from previously published questionnaires with the permission of their
authors [
14
,
15
]. The questionnaire commenced with a demographics section (gender, age,
academic qualifications), followed by questions probing into the respondents’ antibiotic
prescribing practices in relation to endodontic infections. To prevent duplicate data entries
by the same individual, all respondents were required to provide their Serbian Dental
Chamber identification number. To develop the questionnaire, a Google forms
®
free online
survey was utilized as it facilitated direct input of the survey data into a spreadsheet, thus
aiding in subsequent analyses. Prior to its application, the questionnaire (File S1) was
reviewed by the members of the endodontic section of the Department of Dentistry, Faculty
of Medicine, University of Novi Sad. As one of the study goals was to promote compliance
with the ESE recommendations for antibiotic use when treating endodontic infections, all
survey respondents were provided with a link to the relevant files.
Statistical analyses were performed using SPSS
®
25.0 (SPSS, Inc., Chicago, IL, USA).
Chi-squared test of independence was conducted to examine the potential relationships
between nominal variables, with p< 0.05 considered statistically significant. In addition,
Cramer’s V coefficient was calculated to assess the magnitude of correlations between
nominal variables and as a measure of effect size when the Chi-squared test yielded
statistically significant results.
3. Results
The link to the online survey was sent to all 628 dentists practicing in Serbia whose
email addresses were publicly available, resulting in 158 (25.16%) completed questionnaires.
According to surveysystem.com, this corresponded to a confidence interval of 6.75% at a
95% confidence level. The sample comprised of 92 female and 66 male dentists. Nearly
half (48.7%) of the respondents were aged 36–45 years, while those aged 56–65 were the

Antibiotics 2021,10, 67 3 of 11
least represented (10.8%). When asked to indicate their educational attainment, 50.6%
of the respondents indicated that they possessed a Doctor of Dental Medicine (DDM)
undergraduate degree, 13.3% held a Master’s degree in Endodontics, and the remaining
36.1% held a master’s degree in other branches of dentistry. Further analyses revealed a
positive relationship between academic degree and age (p= 0.009), which was expected,
as specialization in any branch of dentistry is a time-consuming process. With regard
to the duration of antibiotic treatment they recommended to their patients, most of the
participating dentists stated that they prescribed a 5-day antibiotic course (Table 1).
Table 1. Duration of antibiotic treatment according to the respondents’ age and academic qualifications.
Treatment
Duration
Age (Years) Academic Qualifications Total
25–35 36–45 46–55 56–65
Doctor of Dental
Medicine (DDM)
Undergraduate
Degree
Master’s
Degree in
Other
Branch of
Dentistry
Master’s
Degree in
Endodontics
3 days 1 (3.3%) 1 (1.3%) 3 (8.8%) 1 (5.9%) 1 (1.3%) 4 (7%) 1 (4.8%) 3.8%
5 days 13 (43.3%) 43 (55.8%) 22 (64.7%) 10 (58.8%) 45 (56.3%) 34 (59.6%) 9 (42.9%) 55.7%
7 days 16 (53.3%) 29 (37.7%) 7 (20.6%) 6 (35.3%) 32 (40%) 16 (28.1%) 10 (47.6%) 36.7%
10 days 0 (0%) 2 (2.6%) 1 (2.9%) 0 (0%) 2 (2.5%) 1 (1.8%) 0 (0%) 1.9%
Until
symptoms
disappear
0 (0%) 2 (2.6%) 1 (2.9%) 0 (0%) 0 (0%) 2 (3.5%) 1 (4.8%) 1.9%
p-value 0.297 0.294
Cramer’s V 0.161 0.174
A larger percentage of respondents who held Master’s degree in Endodontics pre-
scribed a 7-day course of antibiotics compared to those with other qualifications, but this
difference was not statistically significant.
For most respondents, Amoxicillin was the first-choice antibiotic for non-allergic
patients. We, however, found that respondents aged 56–65 prescribed Amoxicillin +
Clavulanic acid 1000 + 62.5 mg and Clindamycin 300 mg more often than dentists from
other age groups, and this difference was statistically significant. On the other hand,
dentists aged 46–55 prescribed Amoxicillin + Clavulanic acid 875 + 125 mg least frequently,
while those aged 46–55 and 56–65 prescribed Azitromycin 500 mg more often than other age
groups. While the aforementioned differences were statistically significant, no association
between academic qualifications and prescribing practices were found (Table 2).
Table 2.
First-choice antibiotics according to the participants’ age and academic qualifications (statistically significant
differences are highlighted in red).
Antibiotic
Age (Years) Academic Qualifications Total
25–35 36–45 46–55 56–65
DDM Under-
graduate
Degree
Master’s Degree
in Other Branch
of Dentistry
Master’s
Degree in
Endodontics
Amoxicilin +
Orvagil 500 +
400 mg
0 (0%) 2 (2.6%) 0 (0%) 0 (0%) 2 (2.5%) 0 (0%) 0 (0%) 1.3%
Amoxicillin
1000 mg 0 (0%) 4 (5.2%) 0 (0%) 0 (0%) 1 (1.3%) 3 (5.3%) 0 (0%) 2.5%
Amoxicillin
250 mg 1 (3.3%) 3 (3.9%) 1 (2.9%) 0 (0%) 1 (1.3%) 4 (7%) 0 (0%) 3.2%
Amoxicillin
500 mg
20
(66.7%)
40
(51.9%)
20
(58.8%) 7 (41.2%) 45 (56.3%) 32 (56.1%) 10 (47.6%) 55.1%

Antibiotics 2021,10, 67 4 of 11
Table 2. Cont.
Antibiotic
Age (Years) Academic Qualifications Total
25–35 36–45 46–55 56–65
DDM Under-
graduate
Degree
Master’s Degree
in Other Branch
of Dentistry
Master’s
Degree in
Endodontics
Amoxicillin +
Metronidazol
500 + 400 mg
0 (0%) 1 (1.3%) 0 (0%) 0 (0%) 1 (1.3%) 0 (0%) 0 (0%) 0.6%
Amoxicillin +
Clavulanic acid
1000 + 62.5 mg
0 (0%) 0 (0%) 0 (0%) 2 (11.8%) 2 (2.5%) 0 (0%) 0 (0%) 1.3%
Amoxicillin +
Clavulanic acid
500 + 125 mg
2 (6.7%) 7 (9.1%) 1 (2.9%) 0 (0%) 3 (3.8%) 4 (7%) 3 (14.3%) 6.3%
Amoxicillin +
Clavulanic acid
875 + 125 mg
1 (3.3%) 5 (6.5%) 0 (0%) 2 (11.8%) 3 (3.8%) 4 (7%) 1 (4.8%) 5.1%
Azithromycin
250 mg 0 (0%) 2 (2.6%) 0 (0%) 0 (0%) 2 (2.5%) 0 (0%) 0 (0%) 1.3%
Azithromycin
500 mg 0 (0%) 0 (0%) 1 (2.9%) 1 (5.9%) 0 (0%) 2 (3.5%) 0 (0%) 1.3%
Clindamycin
300 mg 0 (0%) 0 (0%) 0 (0%) 2 (11.8%) 1 (1.3%) 0 (0%) 1 (4.8%) 1.3%
Clindamycin
600 mg 6 (20%) 11
(14.3%) 9 (26.5%) 3 (17.6%) 16 (20%) 7 (12.3%) 6 (28.6%) 18.%
Dovicin
100 mg 0 (0%) 2 (2.6%) 1 (2.9%) 0 (0%) 3 (3.8%) 0 (0%) 0 (0%) 1.9%
Depending on
the indication 0 (0%) 0 (0%) 1 (2.9%) 0 (0%) 0 (0%) 1 (1.8%) 0 (0%) 0.6%
p-value 0.009 0.369
Cramer’s V 0.365 0.314
For patients that are allergic to penicillin, the majority of respondents prescribed
Clindamycin. No relationship between academic qualifications or age and antibiotic
prescribing practices for patients allergic to penicillin was found (Table 3).
When the participants’ responses related to antibiotic use in different clinical situations
were analyzed, statistically significant differences emerged in relation to acute apical
abscess with systemic involvement (Table 4). In particular, dentists aged 46–55 rarely
prescribed antibiotics in these clinical situations.

Antibiotics 2021,10, 67 5 of 11
Table 3. Antibiotics of choice for patients allergic to penicillin according to the participants’ age and academic qualifications.
Antibiotic
Age (Years) Academic Qualifications
25–35 36–45 46–55 56–65 DDM Undergraduate
Degree
Master’s Degree in Other
Branch of Dentistry
Master’s Degree in
Endodontics Total
Azithromycin 2 (6.7%) 14 (18.2%) 5 (14.7%) 2 (11.8%) 12 (15%) 11 (19.3%) 0 (0%) 14.6%
Clindamycin 21 (70%) 43 (55.8%) 21 (61.8%) 12 (70.6%) 46 (57.5%) 32 (56.1%) 19 (90.5%) 61.4%
Dovicin 0 (0%) 1 (1.3%) 0 (0%) 0 (0%) 1 (1.3%) 0 (0%) 0 (0%) 0.6%
Doxiciklin 0 (0%) 1 (1.3%) 0 (0%) 0 (0%) 1 (1.3%) 0 (0%) 0 (0%) 0.6%
Erithromycin 7 (23.3%) 11 (14.3%) 3 (8.8%) 2 (11.8%) 14 (17.5%) 7 (12.3%) 2 (9.5%) 14.6%
Metronidazole 0 (0%) 4 (5.2%) 3 (8.8%) 1 (5.9%) 4 (5%) 4 (7%) 0 (0%) 5.1%
Roxitromicin 0 (0%) 1 (1.3%) 0 (0%) 0 (0%) 0 (0%) 1 (1.8%) 0 (0%) 0.6%
Tetracycline 0 (0%) 2 (2.6%) 1 (2.9%) 0 (0%) 2 (2.5%) 1 (1.8%) 0 (0%) 1.9%
Depending on the
indication 0 (0%) 0 (0%) 1 (2.9%) 0 (0%) 0 (0%) 1 (1.8%) 0 (0%) 0.6%
p-value 0.885 0.461
Cramer’s V 0.184 0.224
Table 4. Antibiotic use for different clinical indications according to the participants’ age and academic qualifications (statistically significant differences are highlighted in red).
Diagnosis
Age
p-Value
Cramer’s Academic Qualifications
pCramer’s V Total
25–35 36–45 46–55 56–65 V
DDM Under-
graduate
Degree
Master’s Degree
in Other Branch
of Dentistry
Master’s
Degree in
Endodontics
Symptomatic
Irreversible
pulpitis
0 (0%) 1 (1.3%) 1 (2.9%) 0 (0%) 0.713 0.093 2 (2.5%) 0 (0%) 0 (0%) 0.373 0.112 1.3%
Pulp necrosis 0 (0%) 5 (6.5%) 0 (0%) 0 (0%) 0.143 0.185 4 (5%) 1 (1.8%) 0 (0%) 0.380 0.111 3.2%
Acute apical
periodontitis 5 (16.7%)
11 (14.3%)
3 (8.8%) 1 (5.9%) 0.620 0.106 11 (13.8%) 8 (14%) 1 (4.8%) 0.505 0.093 12.7%
Chronic apical
abscess 4 (13.3%) 9 (11.7%) 6 (17.6%) 2 (11.8%) 0.858 0.070 13 (16.3%) 7 (12.3%) 1 (4.8%) 0.371 0.112 13.3%
Acute apical
abscess with no
systemic
involvement
12 (40%)
27 (35.1%)
8 (23.5%) 2 (11.8%) 0.135 0.188 23 (28.8%) 23 (40.4%) 3 (14.3%) 0.072 0.182 31%

Antibiotics 2021,10, 67 6 of 11
Table 4. Cont.
Diagnosis
Age
p-Value
Cramer’s Academic Qualifications
pCramer’s V Total
25–35 36–45 46–55 56–65 V
DDM Under-
graduate
Degree
Master’s Degree
in Other Branch
of Dentistry
Master’s
Degree in
Endodontics
Acute apical
abscess in
medically
compromised
patients
27 (90%)
70 (90.9%) 26 (76.5%) 15 (88.2%)
0.193 0.173 68 (85%) 52 (91.2%) 18 (85.7%) 0.542 0.088 87.3%
Acute apical
abscess with
systemic
involvement
29 (96.7%) 76 (98.7%) 30 (88.2%)
17 (100%) 0.048 0.224 75 (93.8%) 56 (98.2%) 21 (100%) 0.247 0.133 96.2%
Progressive
infections
22 (73.3%) 66 (85.7%) 25 (73.5%) 13 (76.5%)
0.336 0.146 60 (75%) 47 (82.5%) 19 (90.5%) 0.238 0.135 79.7%
Persistent
infections
16 (53.3%) 46 (59.7%) 20 (58.8%) 12 (70.6%)
0.718 0.092 46 (57.5%) 36 (63.2%) 12 (57.1%) 0.780 0.056 59.5%
Post-operative
pain 2 (6.7%) 6 (7.8%) 1 (2.9%) 1 (5.9%) 0.814 0.077 7 (8.8%) 2 (3.5%) 1 (4.8%) 0.440 0.102 6.3%
During endo
treatment 0 (0%) 1 (1.3%) 1 (2.9%) 0 (0%) 0.713 0.093 2 (2.5%) 0 (0%) 0 (0%) 0.373 0.112 1.3%

Antibiotics 2021,10, 67 7 of 11
4. Discussion
This was the first study in which Serbian dentists’ antibiotic prescribing practices
for endodontic infections were examined quantitatively. As indicated earlier, pertinent
data were obtained via an online survey comprised of survey items developed by other
authors, which were replicated or adapted with their permission [
14
,
15
]. According to
https://survey.com/, with 158 (25.16%) of the initially contacted dentists (628) responding
to the survey, this sample size ensured a confidence interval of 6.75% at the 95% confidence
level [
14
]. Unfortunately, despite sending two reminders, a greater response rate could not
be achieved [16].
While the relatively small sample size is a notable limitation of this study, we were
legally not permitted to reach out to the full population of Serbian dentists through the
Serbian Dental Chamber. A further limitation stems from the self-reported nature of the
data, as its veracity could not be established. Consequently, all study findings need to be
interpreted with caution.
The majority of the respondents held a Doctor of Dental Medicine (DDM) under-
graduate degree in dentistry, with a much smaller percentage of those having a master’s
degree (either in endodontics or other branches of dentistry). As specialization in any
branch of dentistry requires at least three years of additional education, as expected, older
participants were more likely to hold a postgraduate degree.
In the treatment of endodontic infections, use of antibiotics is indicated in a small
number of clinical situations, namely for treating acute apical abscesses in medically
compromised patients, acute apical abscesses with systemic involvement, progressive
infections, and persistent infections [
1
]. Considering that endodontic infections are usually
characterized by rapid onset and short duration (2–7 days), when antibiotics are used,
treatment duration of 3–7 days is often sufficient [
3
]. However, patients need to be seen
2–3 days after commencing antibiotic therapy to determine whether treatment should be
stopped or continued [
17
]. In our survey, 55.7% of the respondents indicated that they
typically prescribed a 5-day course of antibiotics, while 36.7% favored a 7-day course.
Prescription period, however, was not correlated with the age or academic qualifications of
respondents (Table 1).
Amoxicillin was the first-choice prescription for patients without an allergy to peni-
cillin for 55.1% of the respondents, irrespective of age or academic qualifications (Table 2).
This finding is in accordance with the results reported by other authors who conducted
similar surveys in Europe [
15
,
18
–
22
]. As Amoxicillin is a
β
-lactam, moderate-spectrum
antibiotic suited for treating oral infections [
1
], to increase its spectrum of action against
Staphilococcus aureus, it is often prescribed in combination with clavulanic acid. In addi-
tion,
β
-lactam antibiotics (Amoxicillin, Penicillin V) are recommended by the European
Society of Endodontology as the first option in the treatment of endodontic infections in
non-allergic patients [
3
]. In Serbia, however, penicillin-containing drugs are marketed only
as a benzylpenicillin powder for injections. For this reason, penicillin is not used by Serbian
dentists, and was not included as one of the options in this survey.
According to the survey results, Clindamycin (600 mg) was the first-choice antibiotic in
the treatment of endodontic infections in patients who are allergic to penicillin, irrespective
of the dentist’s age and qualifications (Table 3). This practice is in agreement with the ESE
recommendations [
3
], and concurs with the findings reported by other authors [
14
,
15
,
20
,
23
].
Clindamycin is a lincosamyde type of antibiotic with a wide spectrum of action and effective
distribution in most body tissues [
1
]. Its concentration in bone is very similar to its plasma
concentration [
24
]. According to the survey findings, for patients allergic to penicillin, most
of the participants would prescribe Azithromycin and Erithromycin as the second choice
(Table 3). Azithromycin belongs to the macrolide group of antibiotics with a wide spectrum
of action and improved pharmacokinetics [
25
]. Erithromycin is also a macrolide antibiotic
with a spectrum similar to that of penicillin, and is the first treatment choice for patients
with an allergy to penicillin in India and Iran [
26
,
27
]. Unfortunately, Kuriyama et al. found

Antibiotics 2021,10, 67 8 of 11
that the Fusobacterium and Prevotella lineages from dentoalveolar infections were resistant
to these antibiotics [28].
The present survey also inquired into the dentists’ antibiotic prescribing practices for
various pulpal and periapical conditions (Table 4). According to the ESE recommendations,
systemic use of antibiotics is necessary only for treating acute apical abscesses in medically
compromised patients, acute apical abscesses with systemic involvement, progressive
infections, and persistent infections [
3
]. Most importantly, antibiotic therapy is contraindi-
cated in symptomatic irreversible pulpitis, pulp necrosis, acute apical periodontitis, chronic
apical abscess, and acute apical abscess with no systemic involvement. According to the
European Society of Endodontology report published in 2006, dental infections can be
successfully treated by pulp extirpation, elimination of the source of infection, drainage, or
tooth extraction [
29
]. In the present survey, only 1.3% of the respondents indicated that they
relied on antibiotics in the treatment of symptomatic irreversible pulpitis (Table 4). This
encouraging result is in accordance with contemporary attitudes and recommendations [
3
].
Similar percentages were reported by other authors: 2% by Skuˇcait
˙
e et al. [
21
], 4.4% by
Mainjot et al. [
19
], 6.2% by Bolfoni et al. [
14
], and 7.4% by Peric et al. [
23
]. It is worth
noting, however, that Tulip and Palmer and Rodriguez-Núñez reported 18% and 31.5%,
respectively for England and Spain [18,20].
Even though it is known that antibiotics are ineffective in treating pulp necrosis [
1
],
3.2% of the survey respondents prescribed antibiotics in such cases (Table 4). Adequate
endodontic treatment followed by three-dimensional obturation and coronal restoration
are the correct and necessary clinical steps for the treatment of pulp necrosis [
30
]. Higher
percentages of antibiotic use in such patients were found by Bolfoni et al. [
14
] and Segura
Egea et al. [15] at 6.2% and 30.7%, respectively.
In cases of acute apical periodontitis with spontaneous pain, pain on percussion and
biting, and widening of periodontal space, systemic antibiotic treatment is not required [
1
].
However, 12.7% of the survey respondents prescribed antibiotics as a treatment for these
conditions (Table 4).
Similar percentage (11.5%) was reported by Bolfoni et al. [
14
], while Segura Egea et al. [
15
]
reported a much higher percentage (71%). Root canal treatment is, in fact, the only rec-
ommended treatment for acute apical periodontitis [
31
,
32
] as well as for chronic apical
abscesses (teeth with sinus tract, periapical radiolucency). However, these recommen-
dations were not followed by 13.3% of our survey respondents (Table 4). According to
this criterion, other investigators have reported a rather diverse prevalence of antibiotic
use, namely Mainjot et al. [
18
] reported 2.7%, Bolfoni et al. [
14
] 20.5%, Rodriguez-Núñez
et al. [
19
] 21.4%, Deniz-Sungur et al. [
32
] 26%, Nabavizadeh et al. [
33
] 58%, and Segura
Egea et al. [15] reported 59.8%.
Even though acute apical abscesses with no systemic involvement characterized by
localized fluctuant swelling do not require systemic usage of antibiotics, but rather root
canal treatment [
1
], 31% of the survey respondents prescribed antibiotics in this situation
(Table 4). Of course, this practice should stop, as antibiotic overuse may lead to antimicro-
bial resistance. Unfortunately, similar findings were reported by other authors: 51.9% by
Mainjot et al. [
18
], 52.9% by Rodriguez-Núñez et al. [
19
], 71% by Segura Egea et al. [
15
],
71.5% by Bolfoni et al. [14], and 74.2% by Nabavizadeh et al. [33].
In acute apical abscesses in medically compromised patients (immunocompromised
patients, patients with locus minoris resistentiae), antibiotic use is indicated because systemic
diseases result in impaired immunologic function [
1
]. In the present survey, 87.3% of the
respondents confirmed that they prescribed antibiotics in these cases (Table 4). No links
between dentist’s age and qualifications with the prescribing pattern could be established.
In other surveys, antibiotic prophylaxis for medically compromised patients is rarely
explored, due to which no comparisons with the findings of other authors can be made.
However, this practice is in line with the ESE criteria [3].
Antibiotics are essential in the treatment of acute apical abscesses with systemic
involvement [
3
]; hence, it is encouraging that 96.2% of the respondents in our study

Antibiotics 2021,10, 67 9 of 11
adhered to these guidelines (Table 4). However, dentists aged 46–55 were statistically
significantly less likely than those in other age groups to have prescribed antibiotics in this
situation. Namely, only 88.2% of respondents in this age group prescribed antibiotics for
acute apical abscesses with systemic involvement, while almost all respondents in other
age groups prescribed antibiotics for treating this condition (Table 4). These results are
comparable with those reported by Bolfoni et al. [
14
], Rodriguez-Núñez et al. [
19
], and
Segura Egea et al. [15] at 88.1%, 94.3%, and 94.5%, respectively.
According to the survey findings, 79.7% of the respondents utilized systemic antibiotic
therapy when treating progressive infections (Table 4), and this is in line with the ESE
recommendations [
3
]. Progressive infection is characterized by a rapid onset of severe
infection (within 24 h), cellulitis or a spreading infection, and osteomyelitis, and thus
necessitates systemic antibiotic therapy.
Persistent infection, manifesting as chronic exudation that is not resolved by regular
intracanal procedures and medications, also requires antibiotic treatment [
3
]. However,
only 59.5% of the survey respondents prescribe antibiotics in such cases (Table 4). This may
suggest failure to keep abreast of the current recommendations and lack of postgraduate
training. As one of the aims of the present study was disseminating the ESE recommenda-
tions to the dentists who completed the questionnaire, this initiative may aid in mitigating
these deficiencies.
For patients experiencing postoperative pain, antibiotics are not indicated; however,
they are prescribed by 6.3% of the survey respondents (Table 4). Postoperative pain is one
of the sequelae that may discourage patients from pursuing root canal therapy. A slightly
lower percentage (4.9%) was reported by Bolfoni et al. [
14
], most likely due to the fact
that their survey specifically targeted Brazilian endodontists, while the majority of the
respondents in our study were dentists.
It is encouraging that, according to this survey, the majority of dentists in Serbia
prescribe antibiotics in clinical situations in which this is warranted. It is also noteworthy
that a small percentage of respondents prescribed antibiotics for treating irreversible
pulpitis, pulp necrosis, acute and chronic apical periodontitis, and acute apical abscess with
no systemic involvement (Table 4). On the other hand, although antibiotics are frequently
prescribed in cases of progressive infections, the percentage should be higher.
Finally, it is reassuring to note that only 1.3% of our survey participants routinely
prescribed antibiotics for patients undergoing endodontic treatment, irrespective of the
diagnosis (Table 4).
Hence, raising the awareness of Serbian dentists of correct antibiotic use in the treat-
ment of endodontic infections is an important step in the global fight against AMR. Such
information dissemination should start during their undergraduate training and regular
updates should be made available to all practicing dentists. In undergraduate educa-
tion, the severity of the AMR phenomenon should be emphasized and the guidelines
for appropriate antibiotic use should be frequently reiterated. Similarly, conferences and
seminars, along with online repositories, are ideal platforms for ongoing education of
dental practitioners at all levels.
5. Conclusions
Despite a relatively small sample size and the self-reported nature of the data analyzed
as a part of this investigation, it can be tentatively concluded that a significant percentage
of Serbian dentists prescribe antibiotics responsibly. Unfortunately, recommendations are
not always followed, and in certain cases, patients are given antibiotics even when this is
not indicated. The disparity between the actual and recommended prescribing practices
supports the need for additional education on responsible antibiotic use. We hope that
by distributing the ESE guidelines to the study participants, we have contributed to this
ongoing endeavor.
Supplementary Materials:
The following are available online at https://www.mdpi.com/2079-638
2/10/1/67/s1, File S1: Questionnaire.

Antibiotics 2021,10, 67 10 of 11
Author Contributions:
Conceptualization, M.D., B.R., M.C. and I.S.; Data curation, K.O.; Investi-
gation, M.C.; Methodology, B.R.; Project administration, M.D.; Supervision, L.P.; Writing—original
draft, M.D. All authors have read and agreed to the published version of the manuscript.
Funding:
This research was funded by Serbian Ministry of Education and Science projects, grant
number 174005, III44003.
Institutional Review Board Statement:
The study was conducted according to the guidelines of
the Declaration of Helsinki, and approved by the Committee of Ethics of the Faculty of Medicine,
University of Novi Sad (01-39/360/1, 11 December 2018).
Informed Consent Statement:
Informed consent was obtained from all subjects involved in the
study.
Data Availability Statement: Data available in a publicly accessible repository.
Conflicts of Interest: The authors declare no conflict of interest.
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