UK unveils plan to tackle antimicrobial resistance: but where do dentists fit in?

In the UK, NHS dentists prescribe just over 5% of all antibiotics. 

Whilst on the face of it this may not sound a lot, consider that in 2017 in England alone, dentists prescribed 2.98 million courses of NHS antibiotics, this not including any antibiotics provided on a private prescription. 

Since every one of these antibiotics could potentially cause the emergence of resistant bacteria (as well as other side-effects), it is vitally important that these risks are weighed up against any potential benefits for the patient. 

However, in a study we conducted in Wales, as many as 81% of the antibiotics prescribed in general dental practice do not adhere to published prescribing guidance and that this may be putting patients at unnecessary risk. So why is this happening? 

The reasons why dentists may prescribe an antibiotic when one is not indicated are complex. Whilst most practitioners would recognise that acute conditions are best managed by local operative treatment, there are instances where the practicalities of this can prove challenging. 

We recognise that clinical time pressures, patients’ unwillingness to undergo surgical interventions, and requests for antibiotics, can all influence prescribing decisions. 

Similarly, there can be instances where local measures fail, or where a patient is unable to cooperate with treatment, which can leave clinicians searching for another course of action.

Firstly, preventing dental problems arising in the first place will mean there is less need to use antibiotics, and therefore a lower risk of resistance. 

This means providing evidence-based preventive interventions, such as fluoride varnish, fissure sealants, and smoking cessation advice when indicated, to prevent dental caries and periodontal disease.

Secondly, we need to use existing antimicrobials only when there is a clear clinical need. There is some evidence that progress towards this has already begun in dentistry. 

The last decade has seen a fall in the number of antibiotics prescribed by dentists of 19.7% in England and 22% in Wales. 

However, it’s not just about when to prescribe, it’s about what to prescribe too. In an audit of antimicrobial prescribing by general dental practitioners in Wales, nearly a fifth of antibiotics prescriptions were for incorrect doses, frequency or duration. 

Of particular concern was the number of excessively long courses of antibiotics (>5 days). 

Since the longer the course of antibiotics, the most likely it is that resistance will occur, all practitioners should be encouraged to refer to clinical guidelines, such as those published by the Scottish Dental Clinical Effectiveness Programme or the Faculty of General Dental Practice (FGDP) before prescribing.  

Thirdly, it’s important that as a profession we try and involve patients and the public, making sure they not only understand what AMR is, but take ownership of the issue and solutions. 

This is likely easier to be said than done, but one potential way of doing this may be to engage patients in a conversation about the appropriate use of antibiotics in dentistry before they present with an acute condition.  

We really need to encourage patients to go to see a dentist if they have a dental infection, rather than going to a GP or to A&E, where it’s likely they’ll be prescribed antibiotics, and just referred back to a dentist for treatment. 

Undertaking clinical audit has been proven to improve antimicrobial use. 

In Wales, Health Education and Improvement Wales have relaunched the national antimicrobial prescribing audit to bring it up-to-date with the recent changes to prescribing guidelines. For more information, please contact Heather Stewart

For practitioners in other areas of the UK, the BDA and partners at the FGDP have released the latest version of their Antimicrobial Prescribing Self-Audit Tool.

Dr Anwen Cope, Specialty Trainee and Honorary Lecturer in Dental Public Health

Cardiff and Vale University Health Board

@anwen_cope

BDA Wales

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