Dr. Susan Sutherland is Chief of Dentistry at Sunnybrook Health Sciences Centre and President of the Canadian Association of Hospital Dentists
Dentists in community practices usually work in isolation from our physician colleagues. Often, dentists prescribe an antibiotic to patients in advance of minor dental procedures like root canal therapy. Evidence shows us that the prophylactic antibiotic use for most patients is not necessary in these cases. And, if the patient develops a C. difficile infection several weeks after the unnecessary antibiotic, the dentist is usually not informed of this until the patient is seen at their next checkup – if at all. Not only do dentists not usually get feedback about the adverse event caused by inappropriate antibiotic use, they are also unaware of their role in the emergence of antimicrobial resistance.
For reasons such as this, the Canadian Association of Hospital Dentists has recently joined the Choosing Wisely Canada campaign. There is an epidemic of unnecessary tests and treatments that the campaign is tackling through conversations within the profession, and with patients. As a profession, dentists need to join this national conversation.
Our list of recommendations highlights how dentists can avoid unnecessary tests and treatments and improve the quality of care we offer to Canadians. This is the first Choosing Wisely list for the dental profession in Canada, and it joins the nearly 50 national clinician societies that have released lists of recommendations. Unnecessary tests and treatment in dentistry are costly to patients, but sometimes they lead to substantial individual and broader social harms.
Four of the eight recommendations on the list address unnecessary antibiotic use. Over 92% of antibiotic prescriptions are made in the community setting, and studies from the United States estimate that dentists make up about a tenth of these prescriptions. We know that there is significant variation around dentists’ prescribing practices. There are efforts underway to better understand the antibiotic prescribing practices of Canadian dentists.
Sometimes due to the costs of a dental visit, or out of an abundance of caution to avoid infection, we offer patients antibiotics for problems such as toothaches, or dental abscesses. This is not evidence based practice and highlighting these through the Choosing Wisely list can help to change our prescribing habits as a profession.
Another major health crisis driven in part by unnecessary prescribing is the opioid epidemic. A recent report from Ontario found that dentists were responsible for 16 % of total opioid prescriptions. With Canada is the grips of an opioid epidemic, dentists need to work with our patients and clinician colleagues to offer non-opioid medications for pain relief. This is why the first recommendation on the Choosing Wisely list is to question the use of opioids for post-operative dental pain, and if opioids are needed then limit the number of tablets dispensed. Not only do these practices avoid harm to our patients, they also avoid harm to our communities as we know that often opioid medications are used inappropriately or diverted by family members or others.
Another area of overuse that the list addresses is dental imaging. Dental x-rays are an important and necessary tool to diagnose and monitor oral-facial disorders and dental diseases. However, one of our recommendations underscores that 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 an arbitrary annual or more routine basis.
Nearly 65% of Canadians visit the dentist annually. Dentists are often the only health care professional that Canadians see each year. As such, we are able to educate the public and influence peoples’ beliefs about the use of antibiotics and opioids, and other important health matters. We are trusted by Canadians to maintain oral health, as well as address emergent issues such as tooth loss, injuries or oral infections. However, dentists also operate primarily outside the publicly-funded health care system, and Canadians pay for our services through insurance or out of pocket. We are trusted to offer patients appropriate and cost-effective services, as well as avoid harms associated with unnecessary tests and treatments. By joining with our Canadian clinician colleagues in the Choosing Wisely Canada campaign, we are moving a step in the right direction towards avoiding harm to our patients, and society, by reducing unnecessary tests and treatments.