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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:dlae082. [PMID: 38779299 PMCID: PMC11109950 DOI: 10.1093/jacamr/dlae082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 05/05/2024] [Indexed: 05/25/2024] Open
Abstract
Objectives Dentistry is a significant contributor to the burden of antimicrobial overprescribing and hence to the global problem of antimicrobial resistance. However, antimicrobial stewardship in Canadian dentistry is nascent, with an acknowledged need for research and coordinated stewardship efforts. This study aimed to gain insights into the perspectives of Canadian dentistry sector leaders and experts on the main drivers of dental antibiotic overprescribing and potential stewardship strategies. Methods Exploratory qualitative design. Data collection: four one-time, 1 h focus group discussions with 22 experts and stakeholders in antimicrobial stewardship in Canada, recruited through a mix of purposive and snowball sampling. Data analysis: inductive thematic analysis. Results The analysis yielded five themes: outdated patterns; antimicrobials as a Band-Aid; fear and risk aversion; behavioural change; and why reinvent the wheel? Overprescription in dentistry stems primarily from a perpetuation of outdated prescribing patterns, ubiquitous use of antibiotics as a temporary solution, and an overly cautious antibiotic use by risk-averse providers. Stewardship strategies should be grounded on behavioural change (motivation, robust data and enactment of new behaviours) and may be modelled after tested medical interventions. Conclusions This study presents a roadmap for behavioural change in dental antibiotic prescribing, and points to the fact that the success of a stewardship actionable plan for Canadian dentistry may depend more on concerted efforts for change than on the creation of novel strategies. Hence, contextualizing and testing medical stewardship programmes in Canadian dentistry may be effective in combatting antibiotic overprescription, thereby contributing to global efforts to reduce antimicrobial resistance.
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Affiliation(s)
- Christiana Martine
- Faculty of Dentistry, University of Toronto, 124 Edward St., Toronto M5G 1X3, ON, Canada
| | - Susan Sutherland
- Faculty of Dentistry, University of Toronto, 124 Edward St., Toronto M5G 1X3, ON, Canada
| | - Karen Born
- Dalla Lana School of Public Health, University of Toronto, 155 College Street, Toronto M5T 3M6, ON, Canada
| | - Wendy Thompson
- Division of Dentistry, University of Manchester, Oxford Road, Manchester M13 9PL, UK
| | - Leanne Teoh
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, 161 Barry St, Carlton VIC 3010, Australia
| | - Sonica Singhal
- Faculty of Dentistry, University of Toronto, 124 Edward St., Toronto M5G 1X3, ON, Canada
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Ramanathan S, Yan C, Suda KJ, Evans CT, Khouja T, Hershow RC, Rowan SA, Gross AE, Sharp LK. Barriers and facilitators to guideline concordant dental antibiotic prescribing in the United States: A qualitative study of the National Dental PBRN. J Public Health Dent 2024. [PMID: 38558016 DOI: 10.1111/jphd.12611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 01/22/2024] [Accepted: 02/09/2024] [Indexed: 04/04/2024]
Abstract
OBJECTIVES While factors contributing to dental antibiotic overprescribing have previously been described, previous work has lacked any theoretical behavior change framework that could guide future intervention development. The purpose of this study was to use an evidence-based conceptual model to identify barriers and facilitators of appropriate antibiotic prescribing by dentists as a guide for future interventions aimed at modifying antibiotic prescribing. METHODS Semi-structured interviews were conducted with dentists from the National Dental Practice Based Research Network (PBRN) exploring patient and practice factors perceived to impact antibiotic prescribing. Audio-recorded telephone interviews were transcribed and independently coded by three researchers. Themes were organized around the COM-B model to inform prospective interventions. RESULTS 73 of 104 dentists (70.1%) were interviewed. Most were general dentists (86.3%), male (65.7%), and white (69.9%). Coding identified three broad targets to support appropriate dental antibiotic prescribing among dentists: (1) increasing visibility and accessibility of guidelines, (2) providing additional guidance on antibiotic prescribing in dental scenarios without clear guidelines, and (3) education and communication skills-building focused on discussing appropriate antibiotic use with patients and physicians. CONCLUSIONS The findings from our study are consistent with other studies focusing on antibiotic prescribing behavior in dentists. Understanding facilitators and barriers to dental antibiotic prescribing is necessary to inform targeted interventions to improve appropriate antibiotic prescribing. Future interventions should focus on implementing multimodal strategies to provide the necessary support for dentists to judiciously prescribe antibiotics.
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Affiliation(s)
- Swetha Ramanathan
- School of Public Health, University of Illinois at Chicago, Chicago, Illinois, USA
- Center of Innovation for Complex Chronic Healthcare, Hines VA Hospital, Hines, Illinois, USA
| | - Connie Yan
- College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Katie J Suda
- Center for Health Equity Research and Promotion, VA Pittsburgh Health System, Pittsburgh, Pennsylvania, USA
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Charlesnika T Evans
- Center of Innovation for Complex Chronic Healthcare, Hines VA Hospital, Hines, Illinois, USA
- Department of Preventive Medicine and Center for Health Services and Outcomes Research, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Tumader Khouja
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ronald C Hershow
- School of Public Health, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Susan A Rowan
- College of Dentistry, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Alan E Gross
- College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Lisa K Sharp
- College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois, USA
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Rawlings A, Hobby AE, Ryan B, Carson-Stevens A, North R, Smith M, Gwyn S, Sheen N, Acton JH. The burden of acute eye conditions on different healthcare providers: a retrospective population-based study. Br J Gen Pract 2024:BJGP.2022.0616. [PMID: 38438268 PMCID: PMC10947371 DOI: 10.3399/bjgp.2022.0616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 06/05/2023] [Indexed: 03/06/2024] Open
Abstract
BACKGROUND The demand for acute eyecare exponentially outstrips capacity. The public lacks awareness of community eyecare services. AIM To quantify the burden of acute eyecare on different healthcare service providers in a national population through prescribing and medicines provision by GPs, optometrists, and pharmacists, and provision of care by accident and emergency (A&E) services. A secondary aim was to characterise some of the drivers of this burden. DESIGN AND SETTING A retrospective data-linkage study set in Wales, UK. METHOD Analysis of datasets was undertaken from the Secure Anonymised Information Linkage Databank (GP and A&E), the Eye Health Examination Wales service (optometry), and the Common Ailments Scheme (pharmacy) during 2017-2018. RESULTS A total of 173 999 acute eyecare episodes delivered by GPs (168 877 episodes) and A&E services (5122) were identified during the study. This resulted in 65.4 episodes of care per 1000 people per year. GPs prescribed a total of 87 973 653 prescriptions within the general population. Of these, 820 693 were related to acute eyecare, resulting in a prescribing rate of 0.9%. A total of 5122 eye-related and 905 224 general A&E attendances were identified, respectively, resulting in an A&E attendance rate of 0.6%. Optometrists and pharmacists managed 51.8% (116 868) and 0.6% (2635) of all episodes, respectively. Older females and infants of both sexes were more likely to use GP prescribing services, while adolescent and middle-aged males were more likely to visit A&E. GP prescribing burden was driven partially by economic deprivation, access to services, and health score. Season, day of the week, and time of day were predictors of burden in GP and A&E. CONCLUSION Acute eyecare continues to place considerable burden on GP and A&E services in Wales, particularly in urban areas with greater economic deprivation and lower overall health. This is likely to increase with a rapidly ageing population. With ongoing pathway development to better utilise optometry and pharmacy, and improved public awareness, there may be scope to change this trajectory.
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Affiliation(s)
- Anna Rawlings
- Swansea University Medical School, Swansea University, Swansea
| | - Angharad E Hobby
- School of Optometry and Vision Sciences, Cardiff University, Cardiff, and University of the West of England, Bristol
| | - Barbara Ryan
- School of Optometry and Vision Sciences, Cardiff University, Cardiff
| | - Andrew Carson-Stevens
- PRIME Centre Wales, Division of Population Medicine, School of Medicine, Cardiff University, Cardiff
| | - Rachel North
- School of Optometry and Vision Sciences and PRIME Centre Wales, Division of Population Medicine, School of Medicine, Cardiff University, Cardiff
| | - Mathew Smith
- School of Pharmacy and Pharmaceutical Sciences, Cardiff University, Cardiff
| | - Sioned Gwyn
- PRIME Centre Wales, Division of Population Medicine, School of Medicine, Cardiff University, Cardiff
| | - Nik Sheen
- Health and Education Improvement Wales (HEIW), Nantgarw
| | - Jennifer H Acton
- School of Optometry and Vision Sciences, Cardiff University, Cardiff
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Musson D, Buchanan H, Nolan M, Asimakopoulou K. Barriers and facilitators to using an objective risk communication tool during primary care dental consultations: A Theoretical Domains Framework (TDF) informed qualitative study. J Dent 2024; 142:104853. [PMID: 38244908 DOI: 10.1016/j.jdent.2024.104853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 01/16/2024] [Accepted: 01/17/2024] [Indexed: 01/22/2024] Open
Abstract
OBJECTIVES Objective risk communication tools can supplement clinical judgement and support the understanding of potential health risks. This study used the Theoretical Domains Framework (TDF) to identify barriers and facilitators to implementing a risk communication aid within primary care dental consultations. METHODS Dentists (N = 13), recruited via a dental practice database and through professional contacts were interviewed using a TDF-informed semi-structured interview schedule. Data were analysed inductively and deductively coding the themes using the TDF. RESULTS Eight theoretical domains (environmental context and resources; beliefs about consequences; goals; memory, attention, and decision processes; optimism; reinforcement; social influences and behavioural regulation) and thirteen sub-themes were identified. Insufficient resources and patient factors were commonly encountered barriers and led to increasing pressure to prioritise other tasks. Whilst dentists had a favourable view towards a risk communication aid and acknowledged its benefits, some were sceptical about its ability to facilitate behaviour change. Self-monitoring strategies and colleague support facilitated tool usage. CONCLUSIONS This study identified six barriers and seven facilitators to implementing a risk communication tool within primary care dental settings. Dentists appreciated the value of using a risk communication tool during dental consultations, although some required further support to integrate the tool into practice. CLINICAL SIGNIFICANCE Our findings provide a sound theoretical base for interventions aimed at facilitating patient behaviour change through the use of risk communication in dentistry. Further research should apply behavioural science to support the implementation of the tool in clinical practice.
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Affiliation(s)
- Danielle Musson
- University of Nottingham, School of Medicine, Faculty of Medicine and Health Sciences, Nottingham, United Kingdom.
| | - Heather Buchanan
- University of Nottingham, School of Medicine, Faculty of Medicine and Health Sciences, Nottingham, United Kingdom
| | | | - Koula Asimakopoulou
- Faculty of Dentistry Oral & Craniofacial Sciences, Kings College London, Centre for Host-Microbiome Interactions, London, United Kingdom
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Acampora M, Paleologo M, Graffigna G, Barello S. Uncovering influential factors in human antibiotic prescribing: a meta-synthesis study informed by the Theoretical Domains Framework. J Hosp Infect 2024; 144:28-55. [PMID: 38092303 DOI: 10.1016/j.jhin.2023.11.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 09/28/2023] [Accepted: 11/30/2023] [Indexed: 01/05/2024]
Abstract
This study aimed to identify modifiable determinants (facilitators and barriers) related to the choice of prescribing antibiotics in human medicine across clinical settings. Enhanced management of antibiotics can help slow the spread of resistant bacteria. A qualitative meta-synthesis approach was used, according to Sandelowski and Barroso's method. Included studies were evaluated using the Critical Appraisal Skills Programme. Findings were extracted and organized to form a qualitative meta-summary. The Theoretical Domains Framework, the Capabilities-Opportunities-Motivation (COM-B) model and the Behaviour Change Wheel were used as a coding matrix for data interpretation. The analysis of 63 included studies revealed barriers and facilitators in 12 of 14 domains specified by the Theoretical Domains Framework. Prescribers' capabilities, motivation and opportunities were found to be the main drivers of antibiotic prescribing behaviour. Knowledge, skills, beliefs, expectations, the influence of patients and colleagues, organizational culture and infrastructure characteristics have a significant impact on prescribing behaviours. A comprehensive inventory of factors related to antibiotic prescribing has been compiled. Interventions to promote appropriate antibiotic prescribing should take a systemic approach rather than focusing solely on individual-level variables. Furthermore, the adoption of co-design approaches for such interventions is desirable to ensure greater applicability and sustainability in the real-world context of organizations.
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Affiliation(s)
- M Acampora
- EngageMinds HUB - Consumer, Food & Health Engagement Research Center, Università Cattolica del Sacro Cuore di Milano e Cremona, Milan and Cremona, Italy; Department of Psychology, Università Cattolica del Sacro Cuore di Milano, Milan, Italy
| | - M Paleologo
- EngageMinds HUB - Consumer, Food & Health Engagement Research Center, Università Cattolica del Sacro Cuore di Milano e Cremona, Milan and Cremona, Italy; Department of Psychology, Università Cattolica del Sacro Cuore di Milano, Milan, Italy
| | - G Graffigna
- EngageMinds HUB - Consumer, Food & Health Engagement Research Center, Università Cattolica del Sacro Cuore di Milano e Cremona, Milan and Cremona, Italy; Department of Psychology, Università Cattolica del Sacro Cuore di Milano, Milan, Italy; Faculty of Agricultural, Food and Environmental Sciences, Università Cattolica del Sacro Cuore di Cremona, Cremona, Italy
| | - S Barello
- Department of Brain and Behavioural Sciences, Università di Pavia, Pavia, Italy.
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Psychological and cultural factors influencing antibiotic prescription. Trends Microbiol 2023; 31:559-570. [PMID: 36720668 DOI: 10.1016/j.tim.2022.12.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 12/21/2022] [Accepted: 12/30/2022] [Indexed: 01/31/2023]
Abstract
Humans have inundated the environment worldwide with antimicrobials for about one century, giving selective advantage to antibiotic-resistant bacteria. Therefore, antibiotic resistance has become a public health problem responsible for increased mortality and extended hospital stays because the efficacy of antibiotics has diminished. Hospitals and other clinical settings have implemented stewardship measures to reduce antibiotic administration and prescription. However, these measures demand multifactorial approaches, including multidisciplinary teams in clinical settings and the education of professionals and patients. Recent studies indicate that individual factors, such as mother-infant attachment and parenting styles, play a critical role in antibiotic use. Also, macrocontextual factors, such as economic, social, or cultural backgrounds, may impact antibiotic use rates. Therefore, research aiming to ameliorate stewardship measures must include psychologically and sociologically based research.
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Sneddon J, Thompson W, Kpobi LNA, Ade DA, Sefah IA, Afriyie D, Goldthorpe J, Turner R, Nawaz S, Wilson S, Hart J, Byrne-Davis L. Exploring the Use of Antibiotics for Dental Patients in a Middle-Income Country: Interviews with Clinicians in Two Ghanaian Hospitals. Antibiotics (Basel) 2022; 11:antibiotics11081081. [PMID: 36009950 PMCID: PMC9404843 DOI: 10.3390/antibiotics11081081] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 08/03/2022] [Accepted: 08/09/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Antimicrobial resistance is a global problem driven by the overuse of antibiotics. Dentists are responsible for about 10% of antibiotics usage across healthcare worldwide. Factors influencing dental antibiotic prescribing are numerous, with some differences in low- and middle-income countries compared with high-income countries. This study aimed to explore the antibiotic prescribing behaviour and knowledge of teams treating dental patients in two Ghanaian hospitals. Methods: Qualitative interviews were undertaken with dentists, pharmacists, and other healthcare team members at two hospitals in urban and rural locations. Thematic and behaviour analyses using the Actor, Action, Context, Target, Time framework were undertaken. Results: Knowledge about ‘antimicrobial resistance and antibiotic stewardship’ and ‘people and places’ were identified themes. Influences on dental prescribing decisions related to the organisational context (such as the hierarchical influence of colleagues and availability of specific antibiotics in the hospital setting), clinical issues (such as therapeutic versus prophylactic indications and availability of sterile dental instruments), and patient issues such as hygiene in the home environment, delays in seeking professional help, ability to access antibiotics in the community without a prescription and patient’s ability to pay for the complete prescription. Conclusions: This work provides new evidence on behavioural factors influencing dental antibiotic prescribing, including resource constraints which affect the availability of certain antibiotics and diagnostic tests. Further research is required to fully understand their influence and inform the development of new approaches to optimising antibiotic use by dentists in Ghana and potentially other low- and middle-income countries.
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Affiliation(s)
- Jacqueline Sneddon
- Healthcare Improvement Scotland, Glasgow G1 2NP, UK
- British Society for Antimicrobial Chemotherapy, Birmingham B1 3NJ, UK
- Correspondence:
| | - Wendy Thompson
- Division of Dentistry, University of Manchester, Manchester M13 9PL, UK
| | - Lily N. A. Kpobi
- Regional Institute for Population Studies, University of Ghana, Legon, Accra P.O. Box LG25, Ghana
| | - Diana Abena Ade
- Regional Institute for Population Studies, University of Ghana, Legon, Accra P.O. Box LG25, Ghana
| | - Israel Abebrese Sefah
- Pharmacy Practice Department, School of Pharmacy, University of Health and Allied Sciences, Ho P.O. Box PMB31, Ghana
- Keta Municipal Hospital, Keta-Dzelukope P.O. Box WT82, Ghana
| | | | - Joanna Goldthorpe
- Division of Medical Education, University of Manchester, Manchester M13 9PL, UK
| | - Rebecca Turner
- Division of Medical Education, University of Manchester, Manchester M13 9PL, UK
| | - Saher Nawaz
- Division of Medical Education, University of Manchester, Manchester M13 9PL, UK
| | - Shona Wilson
- Division of Medical Education, University of Manchester, Manchester M13 9PL, UK
| | - Jo Hart
- Division of Medical Education, University of Manchester, Manchester M13 9PL, UK
| | - Lucie Byrne-Davis
- Division of Medical Education, University of Manchester, Manchester M13 9PL, UK
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Goff DA, Mangino JE, Trolli E, Scheetz R, Goff D. Private Practice Dentists Improve Antibiotic Use After Dental Antibiotic Stewardship Education from Infectious Diseases Experts. Open Forum Infect Dis 2022; 9:ofac361. [PMID: 35959211 PMCID: PMC9361170 DOI: 10.1093/ofid/ofac361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 07/21/2022] [Indexed: 11/25/2022] Open
Abstract
Background Private practice dentists represent 72% of United States dentists. We conducted a prospective cohort study of private practice dentists comparing antibiotic use before and after dental antibiotic stewardship education by infectious diseases (ID) antibiotic stewardship experts. Methods Study phases were as follows: phase 1 (preeducation), 3 months of retrospective antibiotic data and a presurvey assessed baseline antibiotic knowledge; phase 2 (education), dentists attended 3 evening Zoom sessions; phase 3, (posteducation/interventions), 3 months of prospective audits with weekly feedback; phase 4, postsurvey and recommendations to reach more dentists. Results Fifteen dentists participated. Ten had practiced >20 years. Presurvey, 14 were unfamiliar with dental stewardship. The number of antibiotic prescriptions pre/post decreased from 2124 to 1816 (P < .00001), whereas procedures increased from 8526 to 9063. Overall, appropriate use (prophylaxis and treatment) increased from 19% pre to 87.9% post (P < .0001). Appropriate prophylaxis was 46.6% pre and 76.7% post (P < .0001). Joint implant prophylaxis decreased from 164 pre to 78 post (P < .0001). Appropriate treatment antibiotics pre/post improved 5-fold from 15% to 90.2% (P = .0001). Antibiotic duration pre/post decreased from 7.7 days (standard deviation [SD], 2.2 days) to 5.1 days (SD, 1.6 days) (P < .0001). Clindamycin use decreased 90% from 183 pre to 18 post (P < .0001). Postsurvey responses recommended making antibiotic stewardship a required annual continuing education. Study participants invited ID antibiotic stewardship experts to teach an additional 2125 dentists via dental study clubs. Conclusions After learning dental antibiotic stewardship from ID antibiotic stewardship experts, dentists rapidly optimized antibiotic prescribing. Private practice dental study clubs are expanding dental antibiotic stewardship training to additional dentists, hygienists, and patients across the United States.
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Affiliation(s)
- Debra A Goff
- The Ohio State University Wexner Medical Center, The Ohio State University College of Pharmacy ; 410 W. 10th Avenue, Columbus, OH 43210 USA
| | - Julie E Mangino
- The Division of Infectious Diseases in the Department of Internal Medicine at The Ohio State University College of Medicine 1581 Dodd Drive, Suite 400, Columbus OH 43210 USA
| | - Elizabeth Trolli
- The Ohio State University College of Pharmacy 410 W 10th Ave. Columbus OH 43210 USA
| | - Richard Scheetz
- Dr. Scheetz Oral and Facial Surgeon of Ohio 5155 Bradenton Ave, Dublin, OH 43017 USA
| | - Douglas Goff
- Dr’s. Gilbert and Goff Prosthodontists 3360 Tremont Rd. #120, Columbus, OH 43221 USA
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Cooper L, Sneddon J, Thompson W, Guise T, Robertson D, Smith A. Tackling antimicrobial resistance in practice: dental students’ evaluation of university teaching supplemented by an online course. JAC Antimicrob Resist 2022; 4:dlac039. [PMID: 35415610 PMCID: PMC8994195 DOI: 10.1093/jacamr/dlac039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 03/16/2022] [Indexed: 11/20/2022] Open
Abstract
Background Antimicrobial resistance (AMR) presents a global threat to public health. Engaging all healthcare professionals including undergraduates in efforts to tackle AMR is vital. Sharing and spreading good practice in teaching on AMR and antimicrobial stewardship (AMS) is a key ambition in Scotland. In 2020, the University of Glasgow Dental School supplemented teaching with mandatory completion by final year undergraduates of an online education programme on the essential role of dental teams in reducing AMR. Objectives To evaluate final year dental students’ knowledge and experience of utilizing an online international educational, interactive resource to supplement university teaching: Tackling Antibiotic Resistance: What Should Dental Teams Do? Methods Cross-sectional qualitative evaluation using a self-administered questionnaire with open questions about course content, learning and personal action planning. Data were thematically analysed using NVivo12 Pro software. Results A total of 88 students completed a questionnaire, which indicated online training had increased their understanding of AMR and AMS from a global perspective and confirmed these topics were an integral part of their undergraduate education programme. Their action plans demonstrated enthusiasm for creating an AMS culture in clinical practice and an understanding of the need for ongoing education of themselves, their colleagues and patients. Conclusions Education delivery using a variety of media to support teaching and learning in Glasgow Dental School was effective in ensuring that students understand their role in tackling AMR. Students were positive about the addition of an online education programme to supplement university teaching. This approach may be beneficial for other undergraduate dentistry programmes.
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Affiliation(s)
- Lesley Cooper
- Scottish Antimicrobial Prescribing Group, Healthcare Improvement Scotland, Glasgow, UK
| | - Jacqueline Sneddon
- Scottish Antimicrobial Prescribing Group, Healthcare Improvement Scotland, Glasgow, UK
- British Society for Antimicrobial Chemotherapy, Birmingham, UK
| | - Wendy Thompson
- Division of Dentistry, University of Manchester, Manchester, UK
| | - Tracey Guise
- British Society for Antimicrobial Chemotherapy, Birmingham, UK
| | | | - Andrew Smith
- Scottish Antimicrobial Prescribing Group, Healthcare Improvement Scotland, Glasgow, UK
- Dental School, University of Glasgow, Glasgow, UK
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10
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Sato M, Yamana H, Ono S, Ishimaru M, Matsui H, Yasunaga H. Trends in prophylactic antibiotic use for tooth extraction from 2015 to 2018 in Japan: An analysis using a health insurance claims database. J Infect Chemother 2021; 28:504-509. [PMID: 34973876 DOI: 10.1016/j.jiac.2021.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 11/30/2021] [Accepted: 12/15/2021] [Indexed: 10/19/2022]
Abstract
INTRODUCTION To describe patterns in antibiotic prophylaxis for tooth extraction following the 2016 Japanese National Action Plan on Antimicrobial Resistance. METHODS Using a health insurance claims database, we retrospectively identified tooth extraction visits by patients aged ≥18 years from September 2015 to August 2018 and classified patients as undergoing extraction of a fully impacted or horizontally impacted mandibular wisdom tooth, being at risk of infective endocarditis or surgical site infection, or being at low risk. Antibiotic use and type of antibiotics prescribed on the day of tooth extraction were evaluated across the study period, with stratification by tooth extraction category and facility type (hospital or dental clinic). RESULTS We identified 662,435 patients with tooth extraction. The mean age was 42.7 years, and 57% were male. Twelve percent underwent wisdom tooth extraction, 32% were high risk, and 10% visited hospitals. The proportion of antibiotic use was 83% overall and 82% among low-risk patients. This proportion remained similar throughout the study period. A shift from third-generation cephalosporins to amoxicillin was observed from 2015 to 2018: the proportion prescribed third-generation cephalosporins decreased from 58% to 34% in hospitals and from 57% to 56% in clinics, and the proportion prescribed amoxicillin increased from 16% to 37% in hospitals and from 6% to 10% in clinics. CONCLUSIONS The pattern of prophylactic antibiotic use for tooth extraction gradually changed after the initiation of the National Action Plan. Further efforts are required to reduce potentially inappropriate prescriptions for low-risk patients, especially in dental clinics.
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Affiliation(s)
- Misuzu Sato
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan.
| | - Hayato Yamana
- Department of Health Services Research, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan.
| | - Sachiko Ono
- Department of Eat-loss Medicine, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan.
| | - Miho Ishimaru
- Department of Health Services Research, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan.
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan.
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan.
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11
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Duncan EM, Goulao B, Clarkson J, Young L, Ramsay CR. 'You had to do something': prescribing antibiotics in Scotland during the COVID-19 pandemic restrictions and remobilisation. Br Dent J 2021:10.1038/s41415-021-3621-8. [PMID: 34815483 PMCID: PMC8609985 DOI: 10.1038/s41415-021-3621-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 10/18/2021] [Indexed: 11/09/2022]
Abstract
Introduction The COVID-19 pandemic brought about seismic change for dentistry including the direction to provide remote advice and prescribe analgesia and antimicrobials. The possibilities for care have widened, but the impact of both restrictions and remobilisation on antibiotic prescribing is not known.Aims To report the impact of COVID-19 restrictions and remobilisation on dental antibiotic prescriptions and explore dentists' intentions and attitudes towards antibiotic prescribing.Design and setting Public Health Scotland national prescribing and claims data are reported alongside an online survey of Scottish general and public health service dentists including closed and open-ended questions.Results Antibiotic prescribing rose by 49% following the suspension of routine dental care, to a peak of 34,993 antibiotics (July 2020). The data also show that since the remobilisation of NHS dental care, antibiotic prescribing remains raised at levels around 28% higher than pre-pandemic. The survey highlights dentists' frustrations and concerns about this increased use of antibiotics. Most dentists intend to reduce their prescribing; however, significant challenges to this being realised were raised.Conclusions The previous success within dentistry to protect against the development of antimicrobial resistance has suffered a knock-back during the pandemic. A renewed focus on reducing unnecessary antibiotics within dentistry is required but, crucially, needs to be approached sensitively alongside the current backdrop of challenges within the service.
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Affiliation(s)
- Eilidh M Duncan
- Health Services Research Unit, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK.
| | - Beatriz Goulao
- Health Services Research Unit, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Janet Clarkson
- NHS Education for Scotland, Edinburgh, UK; Dental Health Services Research Unit, School of Dentistry, University of Dundee, Dundee, UK
| | | | - Craig R Ramsay
- Health Services Research Unit, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
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12
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Al-Nashi Elia R, Ikram J, Clayton T, Chow V, Aldred E, Pilotille K, Stones N, Mustufvi Z. Primary care research: views of a dental team on their experiences of a primary care study. Prim Dent J 2021; 10:75-80. [PMID: 34727767 DOI: 10.1177/20501684211030087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | - Javed Ikram
- Advisor to Strategic Group College of General Dentistry and General Dental Practitioner, Lytham St Annes, UK
| | | | | | | | | | | | - Zhain Mustufvi
- NIHR Academic Clinical Fellow, University of Leeds, Leeds, UK
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13
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Holloway J. Understanding behaviour change to promote regular dental attendance. Prim Dent J 2021; 10:55-61. [PMID: 34727773 DOI: 10.1177/20501684211029424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Regular dental attendance is a key oral health behaviour. Behaviour change interventions are increasingly being used to promote positive oral health behaviours. A systematic approach to understanding behaviour has led to the development of frameworks which aim to guide the process of designing behaviour change interventions. One such framework is the Behaviour Change Wheel (BCW). This article aims to explore and identify barriers to regular dental attendance which may be targeted using behaviour change interventions based on the Capability, Opportunity and Motivation Behaviour model (COM-B) and the BCW, and suggests potential behaviour change techniques which could be utilised into a behaviour change intervention with the aim to promote regular dental attendance.
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Affiliation(s)
- Jessica Holloway
- General Dental Practitioner, Clinical Lecturer in Restorative Dentistry and Postgraduate Researcher (PhD Student), Bristol Dental School, University of Bristol, UK
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14
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Thompson W, Sandoe J, Pavitt S, Walsh T, Byrne-Davis L. Co-Developing an Antibiotic Stewardship Tool for Dentistry: Shared Decision-Making for Adults with Toothache or Infection. Antibiotics (Basel) 2021; 10:antibiotics10111345. [PMID: 34827283 PMCID: PMC8615064 DOI: 10.3390/antibiotics10111345] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Revised: 10/31/2021] [Accepted: 11/02/2021] [Indexed: 11/16/2022] Open
Abstract
Dentistry is responsible for around 10% of antibiotic prescribing across global healthcare, with up to 80% representing inappropriate use. Facilitating shared decision-making has been shown to optimise antibiotic prescribing (antibiotic stewardship) in primary medical care. Our aim was to co-develop a shared decision-making antibiotic stewardship tool for dentistry. Dentists, patients and other stakeholders prioritised factors to include in the new tool, based on previous research (a systematic review and ethnographic study) about dentists’ decision-making during urgent appointments. Candidate behaviour-change techniques were identified using the Behaviour Change Wheel and selected based on suitability for a shared decision-making approach. A ‘think aloud’ study helped fine-tune the tool design and Crystal Marking ensured clarity of messaging. The resulting paper-based worksheet for use at point-of-care incorporated various behaviour change techniques, such as: ’information about (and salience of) health consequences’, ‘prompts and cues’, ‘restructuring the physical (and social) environment’ and ‘credible sources’. The think aloud study confirmed the tool’s acceptability to dentists and patients, and resulted in the title: ‘Step-by-step guide to fixing your toothache.’ Further testing will be necessary to evaluate its efficacy at safely reducing dental antibiotic prescribing during urgent dental appointments in England and, with translation, to other dental contexts globally.
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Affiliation(s)
- Wendy Thompson
- Division of Dentistry, University of Manchester, Manchester M13 9PL, UK;
- School of Dentistry, University of Leeds, Leeds LS2 9JT, UK;
- Correspondence: ; Tel.: +44-7837-190-387
| | | | - Sue Pavitt
- School of Dentistry, University of Leeds, Leeds LS2 9JT, UK;
| | - Tanya Walsh
- Division of Dentistry, University of Manchester, Manchester M13 9PL, UK;
| | - Lucie Byrne-Davis
- Division of Medical Education, University of Manchester, Manchester M13 9PL, UK;
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15
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Powell HE. Dentists deployed: an insider's perspective of life on the NHS front line. Prim Dent J 2021; 10:21-29. [PMID: 34727769 DOI: 10.1177/20501684211034013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The COVID-19 pandemic has stretched and overburdened healthcare services within the UK. This national crisis has led to the widespread redeployment of healthcare workers and reorganization of services throughout the NHS in the UK. The flexible and altruistic nature of healthcare workers has been inspiring, and central in the UK's response to the COVID-19 pandemic. This article describes the 'first-hand' experience of a secondary care dentist, highlighting the redeployment journey to the emergency department (ED) of a major trauma hospital in the North-West of England during the first wave of the COVID-19 pandemic.
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Affiliation(s)
- Harriet E Powell
- Specialty Dentist, Paediatric Dentistry, Manchester Dental Hospital, UK
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16
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Böhmer F, Hornung A, Burmeister U, Köchling A, Altiner A, Lang H, Löffler C. Factors, Perceptions and Beliefs Associated with Inappropriate Antibiotic Prescribing in German Primary Dental Care: A Qualitative Study. Antibiotics (Basel) 2021; 10:antibiotics10080987. [PMID: 34439037 PMCID: PMC8389002 DOI: 10.3390/antibiotics10080987] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 08/12/2021] [Accepted: 08/13/2021] [Indexed: 11/21/2022] Open
Abstract
Dentists account for up to 10% of all prescribed antibiotics in primary care, with up to 80% being inappropriate. Targeted approaches to change prescription behavior are scarce. This study aimed at identifying specific barriers and facilitators for prudent antibiotic use in German dentistry by using qualitative methods. Nine in-depth interviews and two focus group discussions with another nine dentists were conducted and analyzed thematically. Dentists described being conflicted by the discordance of available treatment time and the necessity of thorough therapy. Lacking the opportunity of follow-up led to uncertainty. Dentists felt a lack of medical competency concerning prophylaxis for infectious endocarditis. A lack of empowerment to make therapeutic decisions interfered with guideline-conformity. The communication with fellow physicians is conflictual and improvement was wished for. In consequence, dentists felt pressure by potential medico-legal liability. Patients demanding quick and easy pain relief put extra strain on the interviewed dentists. Our hypotheses concord with preliminary data, mainly from the UK, but highlighted specifically medico-legal concerns and interprofessional communication as even greater barriers as described before. Tailored interventional concepts based on our findings may have the potential to lower antibiotic prescriptions in German primary dental care.
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Affiliation(s)
- Femke Böhmer
- Institute of General Practice, Rostock University Medical Center, 18057 Rostock, Germany; (A.A.); (C.L.)
- Correspondence:
| | - Anne Hornung
- Rostock University Library, Rostock University Medical Center, 18059 Rostock, Germany;
| | - Ulrike Burmeister
- Department of Operative Dentistry and Periodontology, Rostock University Medical Center, 18057 Rostock, Germany; (U.B.); (H.L.)
| | - Anna Köchling
- Clinic for Psychosomatic Medicine and Psychotherapy, Rostock University Medical Center, 18147 Rostock, Germany;
| | - Attila Altiner
- Institute of General Practice, Rostock University Medical Center, 18057 Rostock, Germany; (A.A.); (C.L.)
| | - Hermann Lang
- Department of Operative Dentistry and Periodontology, Rostock University Medical Center, 18057 Rostock, Germany; (U.B.); (H.L.)
| | - Christin Löffler
- Institute of General Practice, Rostock University Medical Center, 18057 Rostock, Germany; (A.A.); (C.L.)
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17
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Wilding S, Kettu V, Thompson W, Howard P, Jeuken LJC, Pownall M, Conner M, Sandoe JAT. Development and randomized controlled trial of an animated film aimed at reducing behaviours for acquiring antibiotics. JAC Antimicrob Resist 2021; 3:dlab083. [PMID: 34223142 PMCID: PMC8251327 DOI: 10.1093/jacamr/dlab083] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 05/17/2021] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Antimicrobial resistance (AMR) is a global health crisis but reducing antibiotic use can help. Some antibiotic use is driven by patient demand. OBJECTIVES To develop an intervention to discourage antibiotic-seeking behaviour in adults. METHODS Literature reviewed to identify behaviours for acquiring antibiotics among adults in the community. Behaviour change wheel approach was used to select the target behaviour and behaviour change techniques. An intervention in the form of a short animated film was developed and its potential impact evaluated in a randomized, controlled, online questionnaire study. RESULTS Asking a general medical/dental practitioner for antibiotics was identified as the target behaviour. A short stop-motion animated film was chosen to deliver several behaviour-change techniques. Education and persuasion were delivered around information about the normal microbial flora, its importance for health, the negative effect of antibiotics, and about AMR. 417 UK-based individuals completed the questionnaire; median age 34.5 years, 71% female, 91% white ethnicity. 3.8% of participants viewing the test film intended to ask for antibiotics compared with 7.9% viewing the control film. Test film viewers had significantly higher knowledge scores. At 6 week follow up, knowledge scores remained significantly different, while most attitude and intention scores were not different. CONCLUSIONS Some patients continue to ask for antibiotics. The film increased knowledge and reduced intentions to ask for antibiotics. At 6 weeks, knowledge gains remained but intentions not to ask for antibiotics had waned. Evaluation in the clinical environment, probably at the point of care, is needed to see if antibiotic prescribing can be impacted.
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Affiliation(s)
- Sarah Wilding
- School of Psychology, University of
Leeds, Leeds, UK
| | | | - Wendy Thompson
- Division of Dentistry, University of
Manchester, Manchester, UK
| | - Philip Howard
- School of Healthcare, University of
Leeds, Leeds, UK
- Leeds Teaching Hospitals NHS Trust,
Leeds, UK
| | - Lars J C Jeuken
- School of Biomedical Sciences, University of
Leeds, Leeds, UK
| | | | - Mark Conner
- School of Psychology, University of
Leeds, Leeds, UK
| | - Jonathan A T Sandoe
- Leeds Teaching Hospitals NHS Trust,
Leeds, UK
- Leeds Institute of Medical Research, School of
Medicine, University of Leeds, Leeds, UK
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18
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Emmott R, Barber SK, Thompson W. Antibiotics and toothache: a social media review. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2021; 29:210-217. [PMID: 33880539 DOI: 10.1093/ijpp/riaa024] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 12/24/2020] [Indexed: 11/14/2022]
Abstract
OBJECTIVES Antibiotics are inappropriate for the treatment of toothache, yet many seek them. Social media allows users to express their opinions, share experiences and offer support. This study used social media to investigate the public's experiences of, and attitudes towards, antibiotics for toothache. METHODS A systematic search of posts on Facebook and Twitter was undertaken. Eligibility criteria were applied to select relevant social media posts for thematic analysis of word content. An inductive descriptive coding system was developed from the data and exemplary quotes were identified to illustrate the themes and subthemes identified. Key findings Searches identified 174 posts, of which 144 were selected for analysis. Five themes were identified: experience and expectations, self-care and professional treatment, access to dental care, quality of life and coping strategies. The belief that antibiotics are an appropriate treatment for a toothache was widespread. Antibiotic-seeking behaviour was related to access to professional dental care, including avoiding dental appointments due to dental anxiety and the perceived affordability of dentistry. A range of strategies to cope with the severe impact toothache was having on people's quality of life were identified, from prayer to antibiotics. CONCLUSIONS Social media is used extensively to seek antibiotics, avoid dental treatment and provide support to people with toothache. A general belief that antibiotics are an appropriate and necessary treatment for toothache exists. This improved understanding about the factors driving antibiotic-seeking behaviour provides new targets for the development of approaches to tackling antibiotic resistance, by reducing unnecessary antibiotic use in dental clinics and beyond.
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Affiliation(s)
- Rachel Emmott
- School of Dentistry, University of Leeds, Leeds, United Kingdom
| | - Sophy K Barber
- School of Dentistry, University of Leeds, Leeds, United Kingdom
| | - Wendy Thompson
- Division of Dentistry, University of Manchester, Manchester, United Kingdom
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19
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Patterns of dental antibiotic prescribing in 2017: Australia, England, United States, and British Columbia (Canada). Infect Control Hosp Epidemiol 2021; 43:191-198. [PMID: 33818323 DOI: 10.1017/ice.2021.87] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE Our objective was to compare patterns of dental antibiotic prescribing in Australia, England, and North America (United States and British Columbia, Canada). DESIGN Population-level analysis of antibiotic prescription. SETTING Outpatient prescribing by dentists in 2017. PARTICIPANTS Patients receiving an antibiotic dispensed by an outpatient pharmacy. METHODS Prescription-based rates adjusted by population were compared overall and by antibiotic class. Contingency tables assessed differences in the proportion of antibiotic class by country. RESULTS In 2017, dentists in the United States had the highest antibiotic prescribing rate per 1,000 population and Australia had the lowest rate. The penicillin class, particularly amoxicillin, was the most frequently prescribed for all countries. The second most common agents prescribed were clindamycin in the United States and British Columbia (Canada) and metronidazole in Australia and England. Broad-spectrum agents, amoxicillin-clavulanic acid, and azithromycin were the highest in Australia and the United States, respectively. CONCLUSION Extreme differences exist in antibiotics prescribed by dentists in Australia, England, the United States, and British Columbia. The United States had twice the antibiotic prescription rate of Australia and the most frequently prescribed antibiotic in the US was clindamycin. Significant opportunities exist for the global dental community to update their prescribing behavior relating to second-line agents for penicillin allergic patients and to contribute to international efforts addressing antibiotic resistance. Patient safety improvements will result from optimizing dental antibiotic prescribing, especially for antibiotics associated with resistance (broad-spectrum agents) or C. difficile (clindamycin). Dental antibiotic stewardship programs are urgently needed worldwide.
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Shah S, Wordley V, Thompson W. How did COVID-19 impact on dental antibiotic prescribing across England? Br Dent J 2020; 229:601-604. [PMID: 33188343 PMCID: PMC7662720 DOI: 10.1038/s41415-020-2336-6] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 10/14/2020] [Indexed: 11/09/2022]
Abstract
Introduction Antibiotic resistance is a global problem driven by unnecessary antibiotic use. Between 25 March-8 June 2020, COVID-19 restrictions severely reduced access to dentistry in England. Dental practices were instructed to manage patients remotely with advice, analgesics and antibiotics, where appropriate.Aim To describe the impact of the policy to restrict dental access on antibiotic prescribing.Methods NHS Business Services Authority 2018-2020 data for England were analysed to describe national and regional trends in dental antibiotic use.Results Antibiotic prescribing in April to July 2020 was 25% higher than April to July 2019, with a peak in June 2020. Some regions experienced greater increases and for longer periods than others. The increase was highest in London (60%) and lowest in the South West (10%). East of England had the highest rate of dental antibiotic prescriptions per 1,000 of the population every month over the study period (April to July 2020).Conclusion Restricted access to dental care due to COVID-19 resulted in greatly increased dental antibiotic prescribing, against an otherwise downward trend. As dental care adapts to the COVID-19 era, it is important to ensure access for all to high-quality urgent dental care. Understanding the reasons for variation will help to optimise the use of antibiotics in the future.
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Affiliation(s)
- Sagar Shah
- Clinical Fellow, NHS Business Services Authority, 1 St Anne's Road, Eastbourne, East Sussex, BN21 3UN, UK
| | | | - Wendy Thompson
- NIHR Clinical Lecturer in Primary Dental Care, Division of Dentistry, University of Manchester, Couplands 3, Oxford Road, Manchester, M13 9PL, UK.
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