Using antibiotics wisely: A toolkit to reduce overuse of antibiotics

Antimicrobial resistance (AMR) continues to be a critical threat to global health, and the health of Canadians. It is estimated that bacterial AMR was directly responsible for 1.27 million global deaths in 2019 and contributed to 4.95 million deaths.¹ AMR is an escalating problem in Canada. Nationally, about 5500 deaths annually are attributed to AMR, 26% of infections in Canadians are resistant to first-line antimicrobials and six deaths per day in Ontario are attributed to AMR.² Modeling of the Canadian data suggests that by 2050, resistance rates are likely to rise to 40%, resulting in 396,000 deaths between 2020 and 2050 and a GDP decline of $388 billion in that period.² Dentists have a significant role to play in addressing the AMR public health crisis, as do all prescribers, patients and the public. Raising awareness through effective communication to these diverse audiences, and offering accessible education to explain the drivers of this crisis are critical.³

AMR occurs when microorganisms become resistant to the drugs used to treat them. Antibiotics apply selective pressure on bacteria to develop resistant strains by killing susceptible bacteria, allowing antibiotic-resistant bacteria to survive and multiply.⁴ There is a common misconception among both prescribers and patients, that a person develops resistance to an antibiotic, whereas it is the bacteria causing their infection that is resistant. Resistant bacteria can spread from one person to another, as we have seen in hospitals and other clinical settings where an outbreak of an infection by a “superbug” such as Methicillin-resistant Staphylococcus aureus (or MRSA) can have devastating effects.⁵ MRSA is resistant to many antibiotics and is difficult to treat. At least 2% of people carry MRSA and it has become an increasing problem in the community, where community associated MRSA (CA-MRSA) can spread rapidly among healthy people in the community, and frequently cause infections in health care environments as well.⁶

One of the main drivers of AMR is overuse of antimicrobial drugs. Compounding that is the fact that there are few new antibiotics coming to market. Research and development (R&D) of any new drug is very expensive and takes a long time, due to the scientific rigor required, as well the strict trial design and safety requirements of regulators.⁶ One can appreciate that the investment required balanced against the possibility of the new antibiotic becoming useless due to resistance, puts the R&D of new antibiotics in jeopardy.

Dentists and antibiotics

About 80% of antibiotics used in health care are prescribed in the community⁷ and, of those, around 10% are prescribed by dentists.⁸ It is estimated that up to 80% of dental antibiotic prescriptions are unnecessary.^9,10 While overall antibiotic prescribing in the community setting declined by 6.6% from 2019 to 2023, evidence suggests the proportion of community antibiotic prescriptions by dentists is increasing. A British Columbia study found that from 1996 to 2013, antibiotic prescribing among all BC practitioners decreased by 25%, while it increased among dentists by 62%.¹¹ In addition, the use of clindamycin increased by 789%, while amoxicillin prescriptions increased by 143%.¹¹ Other provinces have not captured data tracking antibiotic prescribing by dentists.

Understanding the drivers of antibiotic prescribing and overuse by Canadian dentists is critical and has not been well understood. Martine et al. undertook a series of focus groups of key stakeholders and experts in preparation for a one-day workshop with Canadian dental leaders. They found that drivers of antibiotic use may include old patterns (old habits, beliefs and patient expectations), the need to do something when faced with a patient in severe pain, and risk aversion and fear of litigation.¹² A summary of the results of this study can be found in the article by Martine et al. in this issue. The lack of data on dental antibiotic prescribing was highlighted, as was the importance of consistent, competency-based curricula in undergraduate and postgraduate dental education in Canadian dental schools. Participants spoke about knowledge gaps, lack of consistent up-to-date teaching and clear guidelines, and the need for chairside resources. Aware of the work done in medicine and pharmacy in Canada and in dentistry in the UK and Australia, there was a clear message that we should not “re-invent the wheel”. These findings and an action plan were published in a report of the workshop, “Taking a Bite Out of Antibiotic Prescribing.”¹³

The above work has been the genesis for significant momentum in antimicrobial stewardship in dentistry. There is now a growing awareness of the challenges and opportunities in this area for dentists, a willingness of organized dentistry and governmental organizations to take action, and a commitment by multiple stakeholders to develop attainable action plans. Three areas are actively being pursued. Exploratory work in accessing data on dental prescribing is underway. In addition, researchers at the ten Canadian faculties of dentistry have received a CIHR grant to form a collaboration to ultimately develop AMS educational material specifically designed for Canadian dental schools, such that future dentists are trained in responsible antibiotic prescribing practices. This research has also leveraged ongoing work by the Choosing Wisely Canada campaign on raising awareness about dental antimicrobial overuse.

What is Choosing Wisely Canada?

Choosing Wisely Canada is a campaign to help clinicians and patients engage in conversations about unnecessary tests and treatments and make smart and effective choices to ensure high-quality care. It was launched in 2014 by a team of Canadian physicians as the national voice for reducing unnecessary tests and treatments in Canada. Choosing Wisely encourages conversations between clinicians and patients about care with the following questions:

Do I (does my patient) really need this test, treatment or procedure?
What are the downsides?
Are there safer, simpler treatments?
What happens if we do nothing?

One of the ways in which Choosing Wisely addresses overuse of tests and treatments is through recommendations developed by national clinician societies. National clinician societies conduct an independent review of tests and treatments commonly used in their particular specialty where there is scientific evidence of overuse or harm. These are reviewed by all specialties and become Choosing Wisely Canada recommendations. The recommendations highlight the risks, harms and benefits to encourage a conversation between patients and clinicians.

The “Dentistry List” was developed in 2018 and has been updated annually by the Canadian Association of Hospital Dentists. Because the recommendations address areas that are important for all practicing dentists and their patients, and not specific to hospital dentistry, the list is now maintained by the Canadian Dental Association. The list includes “Eight Tests and Treatments to Question” and addresses areas such as antibiotic and opioid prescribing, use of radiographs and replacement of serviceable fillings, among others.¹⁴

A new Choosing Wisely toolkit for managing toothache

One of the recommendations in the Dentistry Choosing Wisely list is “Don’t prescribe antibiotics for toothache or localized dental abscess”. In our focus groups and workshop, we heard that patients presenting with severe dental pain are often prescribed antibiotics by dentists and physicians. We also heard that the lack of resources that assist clinicians in decision making and in conversations with patients would be helpful and that we should look at toolkits developed for other conditions as a reference. We partnered with Choosing Wisely, whose toolkits for common conditions, for example The Cold Standard, have been very well received and have made a difference in physician antibiotic prescribing and patient expectations.¹⁵

The toolkit Taking the Bite out of Tooth Pain was developed by an interprofessional group of dentists, physicians and implementation science experts, coordinated by Choosing Wisely staff16. The focus of this toolkit is on managing tooth pain and determining when it is appropriate to prescribe antibiotics. The guidance in this toolkit applies to adult patients, including those with medical complexity who are capable of producing an immune response to a bacterial challenge. It is intended for dentists, physicians, and other health care professionals managing adults presenting with tooth pain in settings where dental treatment may or may not be immediately available.

It provides practical guidance and resources, including frequently asked questions, an educational poster and patient information on alleviating toothaches without antibiotics, as well as providing guidance as to when antibiotics are warranted for patients with dental pain. These resources aim to support dental and primary care professionals in taking a proactive role in antimicrobial stewardship, with a focus on providing patient education as well as enhancing patient care while minimizing the risks associated with antibiotic overuse.

Meeting the Challenge Ahead: Combatting AMR

Dentists have an important role to play as prescribers in reducing antibiotic overuse and educating patients about when an antibiotic is needed, and when it is not, and the very real consequences of antibiotic overuse. Harmonized strategies to curb AMR require creative and multipronged approaches to engage prescribers, patients and the public to do their part to reduce the threat of AMR. As we disseminate this toolkit to dentists and other healthcare providers, we hope that it will be a useful resource. Our work in AMS for Canadian dentists started with understanding the drivers of overprescribing antibiotics for a ubiquitous problem, toothache. This led to the development of the toolkit. We know that Choosing Wisely recommendations can reduce low-value services, but dissemination of the toolkit alone is unlikely to have an impact.^17,18 Our group is currently exploring interventions to aid uptake and implementation of the toolkit to support meaningful change.

Oral Health welcomes this original article.

Financial Disclosure: S. Sutherland received funding from the Universities of Manchester- Melbourne and Toronto Research Fund 2022 for the focus group and workshop projects. S. Sutherland, . Fulop and K. Born received a medical societies grant from Choosing Wisely Canada to develop the toolkit on the management of toothache pain in adults.

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References

Antimicrobial Resistance Collaborators. Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis. Lancet. 2022;399(10325):629-655.
When Antibiotics Fail. Ottawa (ON): TheExpert Panel on the Potential Socio-Economic Impacts of Antimicrobial Resistance in Canada, Council of Canadian Academies 2019. Available at: https://cca-reports.ca/reports/the-potential-socio-economic-impacts-of-antimicrobial-resistance-in-canada/ Accessed January 6, 2025.
Raising awareness and educating on antimicrobial resistance. World Health Organization. https://www.who.int/activities/raising-awareness-and-educating-on-antimicrobial-resistance.
Blaskovitch M. How do bacteria actually become resistant to antibiotics? The Conversation, 2023 https://theconversation.com/how-do-bacteria-actually-become-resistant-to-antibiotics-213451.
Turner NA, Sharma-Kuinkel BK, Maskarinec SA, et al. Methicillin-resistant Staphylococcus aureus: an overview of basic and clinical research. Nat Rev Microbiol. 2019;17(4):203-218.
David MZ, Daum RS. Community-associated methicillin-resistant Staphylococcus aureus: epidemiology and clinical consequences of an emerging epidemic. Clin Microbiol Rev. 2010;23(3):616-687.
Smith G, Crago AL, Alexandre S, et al. Prevalence and correlates of oral antibiotic use in Canada. Can Commun Dis Rep. 2024;50(9):312-325.
Canadian Antimicrobial Resistance Surveillance System (CARSS). Antimicrobial Use. Government of Canada. Last updated: 2023/11/24. Available at: https://health-infobase.canada.ca/carss/amu/results.html?ind=03. In.
Suda KJ, Roberts RM, Hunkler RJ, Taylor TH. Antibiotic prescriptions in the community by type of provider in the United States, 2005-2010. J Am Pharm Assoc (2003). 2016;56(6):621-626 e621.
Thompson W, Teoh L, Hubbard CC, et al. Patterns of dental antibiotic prescribing in 2017: Australia, England, United States, and British Columbia (Canada). Infect Control Hosp Epidemiol. 2022;43(2):191-198.
Marra F, George D, Chong M, Sutherland S, Patrick DM. Antibiotic prescribing by dentists has increased: Why? J Am Dent Assoc. 2016;147(5):320-327.
Martine C, Sutherland S, Born K, Thompson W, Teoh L, Singhal S. Dental antimicrobial stewardship: a qualitative study of perspectives among Canadian dentistry sector leaders and experts in antimicrobial stewardship. JAC Antimicrob Resist. 2024;6(3):dlae082.
Sutherland S, Born K, Singhal S, Martine C. 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.
Choosing Wisely Canada: Dentistry. Eight Tests and Treatments to Question. Available: https://choosingwiselycanada.org/recommendation/hospital-dentistry/.
Canadian Institute for Health Information. Overuse of Tests and Treatments in Canada — Progress Report. Ottawa, ON: CIHI; 2022. Available at: https://www.cihi.ca/sites/default/files/document/overuse-of-tests-and-treatments-in-canada-report-en.pdf
Choosing Wisely Canada. Taking the Bite Out of Tooth Pain: A toolkit on using antibiotics wisely for managing tooth pain in adults.2024. Avaiable at: https://choosingwiselycanada.org/toolkit/taking-the-bite-out-of-tooth-pain/?highlight=toothache.
Grimshaw JM, Patey AM, Kirkham KR, et al. De-implementing wisely: developing the evidence base to reduce low-value care. BMJ Qual Saf. 2020;29(5):409-417.
Cliff BQ, Avancena ALV, Hirth RA, Lee SD. The Impact of Choosing Wisely Interventions on Low-Value Medical Services: A Systematic Review. Milbank Q. 2021;99(4):1024-1058.

About the authors

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.

Caroline Fulop received her DMD from the University of Pennsylvania with an Honors designation in Oral Medicine. She completed a hospital dental residency at The Hospital for Sick Children (Toronto, ON) and practices as a hospital based general dentist at The Ottawa Hospital.

LouAnn Visconti received her DDS from the University of Toronto and her Orthodontic Specialty/MSc from the University of Manitoba. Dr. Visconti has presented at meetings of the International Association of Dental Research and has been the first author of peer -reviewed articles and abstracts.

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. Karen served as Knowledge Translation Lead for the Choosing Wisely Canada campaign from 2015–2022.