A national strategy for antimicrobial stewardship (AMS) in Canadian dentistry is much needed. While pharmacy and medicine have long been engaged in significant efforts to control the problem of antimicrobial resistance (AMR), dentistry has fallen behind in terms of organizing a concerted strategy to mitigate this critical problem.1 In 2019 alone, AMR directly caused the deaths of 1.27 million people and has been linked to another 5 million deaths globally.2 When considering that dentistry is responsible for prescribing around 10% of antimicrobials worldwide, and that up to 80% of these may be regarded as unnecessary,3 it has become imperative to develop a Canadian actionable plan to improve antimicrobial management in dentistry, and as such, contribute to global AMS efforts.1
To set in motion an actionable plan for AMS in Canadian dentistry, our team at the University of Toronto held a series of focus group discussions with national and international stakeholders in dentistry during the summer of 2023. The objective of this initial study was to understand perspectives on dental AMS and to inform a subsequent multi-stakeholder workshop that determined the beginnings of an actionable plan. The workshop, entitled “Taking a Bite Out of Antibiotic Prescribing: Developing a sustainable Canadian AMS Strategy in Dentistry” was held in October 2023 at the Faculty of Dentistry, University of Toronto, in a tripartite collaboration with researchers from the Universities of Melbourne and Manchester, as part of the Manchester-Melbourne-Toronto (MMT) Research Fund 2022. Researchers from Ontario, British Columbia, Australia, the United Kingdom, and the United States shared insights and innovations in AMS best practices in their jurisdictions. Both focus groups and the workshop included the participation of health policy leaders, members of governing dental bodies, experts in AMR and AMS, dentists, pharmacists and medical doctors, including infection prevention and control physicians.
In this paper, we provide some of the highlights of our findings, including those from the focus group discussions, which are based on our article published in May 2024,1 and from the multi-stakeholder workshop report.4
Factors contributing to antimicrobial over-prescription in dentistry
Three key factors were identified as drivers of antimicrobial over-prescription in dentistry.1 These factors were connected not only to dentists and other healthcare providers—such as pharmacists and physicians, who are often consulted on an emergency basis when a patient has a toothache— but to patients as well. First, providers may continue to follow prescribing patterns that have become outdated, primarily due to unclear guidelines, a lack of awareness that recommendations have changed, failure to engage in continuing education in the field, or difficulties in changing long-established prescribing habits.1
Second, risk-averse providers often prescribe antimicrobials as a safeguard against the possibility of patients developing an infection, as well as out of fear of regulatory complaints or litigation. The potential negative impact on their practice, along with the legal issues that might arise from such an infection, shapes their reliance on antimicrobials. This tendency is especially pronounced since negative effects on their practice are often seen as more immediate and tangible than the potential complications associated with AMR.1
Third, when dentists are consulted by patients with dental ailments that cannot be treated immediately, dentists may feel they need to act, or feel pressured to provide a “temporary or ‘Band-Aid’ type of solution”1 until proper treatment can be delivered. For instance, when there is no available time on the dentist’s schedule to treat an emergency, or when patients need to see a specialist for their condition, they are often prescribed antimicrobials. Moreover, other providers, such as physicians who also lack clear guidelines on managing tooth pain, and who are not equipped to treat dental conditions directly, resort to prescribing antimicrobials for patients who consult them for dental issues.1
Patients who fear going to the dentist can also contribute to antimicrobial overprescribing in dentistry, since they prefer to seek a provider that can medicate their pain rather than undergo treatment. Furthermore, patients who have been prescribed antibiotics for certain conditions in the past, such as prophylaxis after joint replacements, may expect to be prescribed an antibiotic every time they go to the dentist. In turn, these patients’ expectations can pressure the dentist into prescribing antimicrobials, even for issues that the professional recognizes should not be treated with antibiotics.1
What stakeholders said ….
“I learned this in dental school”
“I’ve always done this …it works”
“You don’t want to take a chance on something blowing up and then have the College come back at you later for not having done everything possible to prevent that ….”
“If I don’t give an antibiotic and the condition worsens, I get blamed. If I prescribe an antibiotic and the patient gets c. difficile, that’s the antibiotic’s fault, right?”
“You know there’s no antibiotic indicated, but you feel like you have to do something to let’s say, get them to the endodontist office”
“When the dentist has a feeling that the patient might not come back because of either the distance or some other social factors and demographic factors, financial reasons”
“We [family doctors] only have one solution. It’s the antibiotics. We don’t know what to do with those dental problems”
Adapted from Martine et al., 2024
Core components of an effective AMS plan for Canadian dentistry
We identified three main priorities for action and collaboration towards an AMS plan for Canadian dentistry: the collection of robust data, better AMS education, and accountability in prescribing.1,4 Moreover, out of these three priorities it was determined that efforts for an actionable plan should commence with the development of data and the education of providers, students, and patients. Data are essential for supporting AMS strategies such as tracking and understanding overprescribing tendencies, addressing the gap between evidence and practice, identifying substandard prescribing behaviors, and ultimately for reducing the incidence of complications and morbidities associated with AMR. Although Canada has universal healthcare, dentistry is primarily privately funded either through insurance benefits, or through out-of-pocket payments, which leads to significant challenges in collecting and centralizing data.4 An estimated 68% of Canadians have dental insurance, and about 75% report visiting a dental professional in the past year.5 Moreover, the limited segments of data that are collected lack communication between them. Thus, any opportunity to gather data should be seized, such as those provided by public dental programs, through stakeholder engagement, including dental associations, health organizations, and governmental bodies. Data should be collected at two different levels. First, nationally, through anonymized, line-listed prescriptions for a detailed analysis of dosage, type of drug, usage, and demographics via national programs such as the Canadian Dental Care Plan, the Non-Insured Health Benefit Plan, and the Canadian Armed Forces. Administrative data should also be collected through institutions such as the Canadian Institute for Health Information. Second, more detailed data should be collected at the provincial level, aiming to guide providers into adopting safer prescribing habits through mentoring, coaching, and supporting AMS interventions such as audit and feedback.4
Enhancing education—targeting both providers and patients, through the training of dental students and retraining of providers, the creation of clear guidelines, and the mobilization of knowledge—is key to mitigating overprescribing in Canadian dentistry. Given the lack of standardization in antimicrobial resistance and stewardship in the curriculum of Canadian dental schools, the first step toward improving the training of dental students would be to examine baseline data and teaching patterns across dental faculties in Canada to understand what is being taught about antimicrobial indications, usage, unintended effects, and the critical gaps in the curriculum. Another environmental scan should be developed in tandem to assess all dental regulatory bodies and associations across Canada’s ten provinces and three territories, with the goal of evaluating the availability and quality of continuing dental education courses as well as to bridge the gap between evidence and real-world practice. Continuing education courses for practicing dentists could be mandatory, and/or free of charge, integrated into the Quality Assurance programs administered by regulatory bodies, and aligned with the curricula of other health sciences, such as medicine and pharmacy. The creation of evidence-based guidelines to clearly stipulate when antimicrobials should be prescribed, as well as the dissemination of knowledge to both providers and patients, should be informed by behavioral theories that can help to address longstanding habits, providers’ fears, and help to withstand patients’ pressures and potential litigation.1,4
Highlights
-Robust data is essential for understanding and reducing over-prescribing of antibiotics in dentistry
-Guidelines provide clear recommendations for best practices, and help patients to make informed decisions
Reproduced from Sutherland et al., 2024
Furthermore, guidelines can help regulators review patients’ complaints judiciously, as well as address those providers who are not in compliance with set standards. Patients and the public should also be educated through knowledge mobilization strategies, similar to those used in BC and Alberta in the “Do Bugs Need Drugs” campaign. These initiatives should be pursued at both the national and provincial levels. Furthermore, the use of devices similar to viral prescription pads used in primary care settings, as well as other shared decision aids that have been disseminated to primary care providers through the Choosing Wisely Canada campaign, can inform patients about the distinction between inflammation/infection and local/systemic infections.4
During workshop discussions, there were robust conversations around whether antimicrobials should be regulated similarly to controlled substances, such as opioids, with some suggesting that such regulation would instill in dental profession the idea that dental AMS is an obligation rather than a choice. An approach similar to the Narcotics Monitoring system, for instance, would in turn lead to the accumulation of robust data, which is also crucial for antimicrobial AMS. Other accountability measures such as record-keeping and monitoring systems should also be used to keep providers accountable.4
Conclusion
Given dentistry’s contribution to the global problem of AMR, it is critical to develop stewardship strategies for dental AMS. The workshop held on October 17th, 2023, and subsequent collation of expert perspectives, marked the beginnings of a coordinated approach to an effective agenda for Canadian dental AMS. While stakeholders acknowledged several challenges for developing effective strategies for AMS in dentistry, they also recognized many opportunities for change.
We identified three priorities for action and collaboration on dental AMS: first, develop and explore any opportunity to collect data; second, enhance the education of providers, students, and patients; and third, promote professional accountability in antimicrobial prescribing. Furthermore, we determined that, out of these three priorities, an effective strategy for Canadian dentistry should commence with better education by creating clear guidelines for providers, examining the curriculum of dental schools in Canada, and reviewing the content of AMR and AMS in continuing education courses. In addition, developing standardized provincial and national data for assessing antimicrobial prescribing is also an immediate priority for action.
| Challenges | Opportunities |
| • Absence of robust data • Old habits, patterns, beliefs, and expectations • Risk aversion, patients’ expectations • Knowledge gaps, lack of consistent up-to-date teaching, clear guidelines, chair-side resources/toolkits | • Growing awareness, many champions • Willingness of organized dentistry and governmental organizations • Potential data sources to explore, nationally and provincially • Education – Pre-licensure, CME |
Oral Health welcomes this original article.
Financial Disclosure: S. Singhal and S. Sutherland received funding from the Universities of Manchester- Melbourne and Toronto Research Fund 2022 for the focus group and workshop projects.
References
- Martine C, Sutherland S, Born K, et al. Dental antimicrobial stewardship: a qualitative study of perspectives among Canadian dentistry sector leaders and experts in antimicrobial stewardship. JAC-AMR 2024.
- Murray CJ, Ikuta KS, Sharara F, et al. Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis. Lancet 2022; 399: 629-55.
- Thompson W, Teoh L, Hubbard C, et al. Patterns of dental antibiotic prescribing in 2017: Australia, England, United States, and British Columbia (Canada). Infect Control Hosp Epidemiol 2022; 43: 191-8.
- Sutherland S, Born K, Singhal S, et al. Taking a bite out of antibiotic prescribing: A workshop report on developing a sustainable antimicrobial stewardship strategy for Canadian dentistry. 2024 Jan. https://caphd.ca/wp-content/uploads/2025/01/Taking-a-bite-out-of-antibiotic-prescribing-January-2024.pdf.
- Moharrami M SY, Murphy K, Hu X, Clarke J, McLeish S, Fortin Y. Assessing the role of dental insurance in oral health care disparities in Canadian adults. 2024 Apr 17. https://www150.statcan.gc.ca/n1/pub/82-003-x/2024004/article/00001-eng.htm.
About the authors
Christiana Martine, PhD, is a clinical instructor at the Faculty of Dentistry, University of Toronto. She also serves as a research associate in the Department of Public Health at the same institution.
Karen Born, PhD is an assistant professor and program director of the M.HSc. in Health Administration at the Institute of Health Policy, Management & Evaluation, Dalla Lana School of Public Health, University of Toronto.
Sonica Singhal, BDS, MPH, PhD is an assistant professor and program director, Dental Public Health discipline, at the Faculty of Dentistry, University of Toronto. Also, is appointed as Scientist, Oral Health, at Public Health Ontario.
Susan Sutherland, DDS MSc is an Associate Professor, Faculty of Dentistry, University of Toronto and staff member in the Department of Dental and Maxillofacial Sciences at Sunnybrook Health Sciences Centre in Toronto. She is a Co-lead for the Canadian Association of Hospital Dentists at Choosing Wisely Canada and a member of the working group that developed the Choosing Wisely toolkit for the management of toothache.
