May 7, 2019
by Susan Sutherland, DDS, MSc; Karen Born, PhD
Earlier this year the Canadian Association of Hospital Dentists joined the Choosing Wisely Canada campaign. Choosing Wisely Canada is the national voice on reducing harm to patients. Modeled on the Choosing Wisely campaign in the United States, an initiative of the American Board of Internal Medicine (ABIM) Foundation, it is a national, clinician-led and grassroots initiative focused on overuse. Overuse in health care is defined as “a health care service [that] is provided under circumstances in which its potential for harm exceeds the possible benefit.1 In the United States, the campaign emerged from a consensus in the United States that a professional, clinician voice was needed in conversations about overuse. While the campaign started with physicians, it has expanded far beyond medicine; engaging associations and societies representing a diverse group of health professionals such as nurses, pharmacists and respiratory therapists.
Overuse is a major health care quality problem. Canadian data suggests that about 30% of all tests and treatments in health care are unnecessary.2 There are many harms to overuse in health care. Overuse can cause harm physically, psychologically and financially to individual patients. An unnecessary diagnostic test with an incidental or false positive often leads to a cascade of additional interventions. Overuse of medications can have harmful interactions and side effects. Overuse is also harmful to health systems, increasing wait times for those who need care, and wasting limited resources including clinician time. Two broad health system and public health crises driven by overuse are the opioid epidemic and antimicrobial resistance. Evidence shows that dentists’ prescribing has contributed to both these public health crises.3
Choosing Wisely is a global campaign. There are more than 20 countries worldwide with existing and planned campaigns. The Choosing Wisely international collaboration helps to foster sharing of campaign innovations, learning and strategies across countries.
About Choosing Wisely Canada
Choosing Wisely campaigns offer an evidence-based, clinician-led voice to identify the problem of overuse in their specialty. Choosing Wisely Canada’s founding partner is the Canadian Medical Association (CMA) and it is based at the University of Toronto. The campaign is funded in part by Health Canada, alongside provincial and territorial ministries of health.
To date, Choosing Wisely Canada has partnered with over 70 clinician societies from different clinical specialties and disciplines to develop lists of “Things Clinicians and Patients Should Question.” These lists contain recommendations of tests, treatments and procedures that are not supported by evidence and could potentially expose patients to harm. Over 300 recommendations have been published since the campaign began.4 Societies follow a set of guiding principles in developing lists, such as that recommendations only relate to common tests/treatments/procedures within their specialty, that recommendation development is evidence-based and transparent. Recommendations distinguish themselves from guidelines as they are succinct and written in plain language. Each recommendation includes a statement that begins with “Don’t” which highlights how the campaign is targeting changing common behaviours in practice. Recommendations are supported by up to date and relevant evidence and references. These recommendations are then shared with members of the society, specialty and more broadly the profession through a number of different mechanisms including conferences, presentations, and articles such as this one. The goal of the campaign has been to raise clinician awareness about overuse, and encourage clinicians to engage in conversations about unnecessary tests and treatments with patients. Evidence shows that conversations and shared decision making can help avoid overuse.
The campaign has a public focus as well. Many of the recommendations have parallel patient information, available on the Choosing Wisely Canada website. In addition, the campaign has engaged in significant social marketing campaigns to patients, providing them with a list of questions to ask a clinician at their clinical encounters. Clinicians often cite patient demands, or expectations, as barriers to avoiding overuse. The campaign works to target patients and the public, and engages in activities to enhance patient and public understanding and education on the harms of overuse.
Impact to date
Choosing Wisely Canada has helped raise awareness about overuse amongst Canadian patients, clinicians and the public. Surveys of physicians have found that over 90% are aware of the campaign, with half saying that they use the recommendations daily in practice. The campaign has also raised awareness about overuse for the general public. A 2019 Ipsos Reid survey found that 18% of Canadians are aware of the campaign. This survey also found that in general, the public understand that overuse and unnecessary tests and treatments are a problem in health care.
Beyond raising awareness, Choosing Wisely Canada has worked on a series of efforts to go beyond the lists of recommendations. This has included supporting clinicians and organizations who are implementing recommendations into practice. When implementation activities have been successful at reducing overuse, tools and strategies used are described and shared to assist others who are interested in doing similar work in their setting. To date, there have been eleven toolkits published, with more under development.
Choosing Wisely Canada is a truly national campaign, working with regional affiliates on local and regional priorities for implementation. Further, there are national and regional measurement initiatives in place to help advance measurement of campaign recommendations and changes at the national, provincial and local level. There are also focused ‘mini-campaigns’ on important priority areas and which are highly relevant to dental practice. The ‘Using Antibiotics Wisely’ campaign is funded by the Public Health Agency of Canada (PHAC) and offers tools to community based prescribers on how to avoid unnecessary antibiotic use. It also includes materials for patients and the public with specific information about the harms of unnecessary antibiotics, as well as questions to ask their health care provider. The ‘Opioid Wisely’ campaign brought together opioid-related recommendations and shared them with family physicians, and had publicly-facing messaging on safer alternatives to opioids.
The campaign is also working in medical education to embed campaign recommendations into undergraduate medical education across Canada’s 17 medical schools. The STARS (Students and Trainees Advocating for Resource Stewardship) campaign fosters student leaders to help raise awareness amongst their peers and faculty about Choosing Wisely and to advocate for more curricular content on avoiding overuse in practice.
Choosing Wisely in Dentistry
The Canadian Association of Hospital Dentists launched a working group to develop a list of recommendations for dentistry and join the campaign. The list of ‘Eight Things Dentists and Patients Should Question’ was released in March 2018. The recommendations are not specific to hospital dentist practice and relate to areas of overuse driven by both dentists and patients. Recommendations highlight opportunities to avoid harm to patients through unnecessary prescriptions and imaging, as well as unnecessary procedures.
About 65% of Canadians visit their dentist at least once per year. For many patients, we are the only health professional that they will encounter each year. Alongside our professional obligations to offer high quality care, we can help educate patients about the harms of overuse, as it relates to oral health and in areas where our practices intersect with major public health issues such as antimicrobial resistance and the opioid crisis.
There are many opportunities for dentists to become involved with Choosing Wisely Canada through their specialty associations. Each specialty knows their area of practice best and understands from daily encounters with patients and colleagues where overuse issues could be addressed. Choosing Wisely Canada is a collegial, energetic and supportive community of practitioners who welcomed and encouraged the first Canadian dental group and would be pleased to assist other dental specialties. Joining the Choosing Wisely Canada campaign offers an exciting opportunity to help improve quality of care and avoid harm to our patients.
Eight Things Dentists and Patients Should Question
The Canadian Association of Hospital Dentists (Last updated: March 2018)
1. Don’t use opioids for post-operative dental pain until optimized dose of Nonsteroidal Anti-inflammatory Drugs (NSAIDs)/Acetaminophen has been used.
For post-operative dental pain, the dose and frequency of a non-opioid (ibuprofen and/or acetaminophen) analgesic should be optimized. If this is not sufficient for managing pain then an opioid may be considered. If an opioid analgesic is appropriate consider limiting the number of tablets dispensed.
2. Don’t prescribe antibiotics for irreversible pulpitis (toothache).
Irreversible pulpitis or toothache occurs when the soft tissue and nerve inside the tooth (the dental pulp) becomes damaged as a result of decay, trauma or large fillings. The intense pain is caused by inflammation of the dental pulp and the tissue surrounding the root – not by infection. Because this is not an infection, antibiotics do not relieve the pain and should not be used. Treatment for this condition is the removal of the damaged or diseased dental pulp, either through root canal therapy or extraction of the tooth. Inflammatory dental pain is best managed by non-steroidal inflammatory drugs.
3. Don’t routinely prescribe antibiotics for acute dental abscess without signs of systemic involvement.
Acute dental abscess is a localized infection that occurs as the result of an untreated infection of the dental pulp. The abscess should be drained and the tooth treated with root canal therapy or extraction of the tooth. Antibiotics are of no additional benefit. In the event of systemic complications (e.g., fever, lymph node involvement or spreading infection), or for an immunocompromised patient, antibiotics may be prescribed in addition to drainage of the tooth.
4. Don’t give prophylactic antibiotics prior to dental procedures to patients with total joint replacement.
Infections of orthopedic implants are uncommon events and are rarely caused by bacteria found in the mouth. Although dental procedures such as extractions cause transient bacteremia, most bacteremia of oral origin occurs with activities of daily living, including brushing, flossing and chewing. There is no reliable evidence that antibiotics prior to dental procedures prevents prosthetic joint infections. Patients should not be exposed to the adverse effects of antibiotics when there is no evidence of benefit.
5. Don’t give prophylactic antibiotics to patients with non-valvular cardiac or other indwelling devices.
There is no convincing evidence that oral bacteria from dental procedures cause infections of the following devices at any time after implantation: pacemakers; implantable defibrillators; ventriculoatrial shunts; devices for patent ductus arteriosus, atrial septal defect, and ventricular septal defect occlusion; peripheral vascular stents; prosthetic vascular grafts; hemodialysis shunts; coronary artery stents; dacron parotid patches; chronic indwelling central venous catheters.
6. Don’t prescribe radiographs without indication.
Dental x-rays are an important and necessary tool to diagnose and monitor oral-facial disorders and dental diseases. The need for x-rays should be determined on an individual basis for each patient, based on medical and dental history, clinical findings and risk assessment, rather than on a routine basis.
7. Don’t replace fillings just because they are old.
Dental restorations (fillings) fail due to excessive wear, fracture of material or tooth, loss of retention, o recurrent decay. The larger the size of the restoration and/or the greater the number of surfaces filled increases the likelihood of failure. Restorative materials have different survival rates and fail for different reasons, but age should not be used as a failure criteria. Drilling to remove and replace fillings can weaken teeth. If feasible, repair of small defects, rather than replacement of a filling, can save tooth structure and increase the lifespan of restorations at a low cost.
8. Don’t remove mercury-containing dental fillings unless the restoration has failed.
Mercury-containing dental fillings release small amounts of mercury. Randomized clinical trials demonstrate that the mercury present in fillings does not produce illness. Removal of such fillings is unnecessary, expensive and subjects the individual to absorption of greater doses of mercury than if left in place. Furthermore, placement of composite resin restorations are known to cause a transient increase in urinary Bisphenol-A levels, for which there are unknown health effects and high quality evidence suggests higher failure rates in composite resins versus filling restorations.
About The Author
Dr. Susan Sutherland is Chief of Dentistry at Sunnybrook Health Sciences Centre and President of the Canadian Association of Hospital Dentists.
Karen Born, PhD, is Knowledge Translation Lead for Choosing Wisely Canada and an Assistant Professor in the Institute of Health Policy, Management and Evaluation at the University of Toronto.
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