In November 2016, a  Dental Antimicrobial Stewardship: toolkit was released.  It was developed in response to findings in the May 2016  Antimicrobial Resistance review by the Dental Subgroup of the English Surveillance Programme for Antimicrobial Utilisation and Resistance (ESPAUR).  It complements these existing standards:   General Dental Council (GDC) standards/guidance and Care Quality Commission (CQC) Fundamental Standards.

The past decade has seen an increased focus in the UK on antimicrobial prescribing practices in dentistry. Primary care dentists were responsible for 5% of all NHS antibacterial prescriptions in 2014.

A recent cross-sectional study of 568 patients that assessed the extent to which antibiotic prescribing in general dental practice in the UK conforms to clinical guidelines found that:

• Antibiotics were prescribed to 57% of patients
• Over half of antibiotics (66%) were prescribed in situations where there was no evidence of spreading infection
• 71% were prescribed without the provision of an operative intervention.
• Only 19% of antibiotics were prescribed in situations where their used was indicated by clinical guidelines

From this study, factors influencing the decision to prescribe antibiotics included:

• Failure of previous treatment
• Shortage of clinical time to undertake treatment
• Patients unable/unwilling to accept operative treatment
• Patient requests for antibiotics
• Acute periodontal conditions

Previous AMS interventions have sought to address gaps in practitioner knowledge through pharmacist-delivered academic detailing and clinical audit that promotes compliance with guidelines. The authors make the point that no interventions to date in the UK have equipped practitioners with the necessary skills or capabilities to modify patient expectation for antibiotics or their reluctance to undergo operative treatment.

In August 2015 the National Institute for Health and Care Excellence (NICE) published Antimicrobial Stewardship: Systems and processes for effective antimicrobial medicine use  and this served as the basis of a recent article by Thompson and Sandoe who examined the applicability of the NICE guideline for dentistry and made dental prescriber recommendations  (see below).

What about the Australian situation?

The Australian Commission on Safety and Quality in Health Care (ACSQHC) safety and quality standards are not mandated for private dental practice in Australia. Furthermore,  there is a dearth of independent published local research  regarding dental antimicrobial use.

In February 2012, the Australian Dental Association (ADA) published this comment in response to a ACSQHC  Consultation Paper, stating: 

“Dental practitioners generally use a limited range of medicines and that prescriptions of antibiotics to support treatment of infections comprise only as small fraction of current antibiotic usage in Australia. Moreover the dental profession has produced its own comprehensive guidelines on the use of antibiotics and other prescription drugs in dentistry, which stress the application of principles of safe prescribing and the quality use of medicines.”

The issue was revisited by C. Daly (then Chair, Dental Therapeutics Committee, ADA) in this short 2013 Australian Prescriber piece, stating:

“In Australia….. dentists have been found to overprescribe antibiotics, particularly penicillins as part of dental treatment. Antibiotics may be inappropriately prescribed for dental pain where operative dental treatment is  the appropriate management” 

Quo vadis? 

AMS in Dentistry remains a neglected realm in Australia that urgently warrants operational research and action by government and professional bodies.  The UK experience and progress can serve as an excellent guide to future action.

Excerpt from recent article by Thompson and Sandoe: 

References

• Cope, A.L., Francis, N.A., Wood, F. and Chestnutt, I.G., 2015. Antibiotic prescribing in UK general dental practice: a cross‐sectional study. Community dentistry and oral epidemiology.
• Daly, C.G., 2013. Antimicrobial stewardship. Aust Prescr: 2013;36:1201.
• Thompson, W. and Sandoe, J.A.T., 2016. What does NICE have to say about antimicrobial prescribing to the dental community?. British dental journal, 220(4), pp.193-195.
• Antimicrobial prescribing by dentists in Wales, UK: findings of the first cycle of a clinical audit.Br Dent J. 2016 Jul 8;221(1):25-30.