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Br Dent J 2016; 221: 25–30 http://dx.doi.org/10.1038/sj.bdj.2016.497

'It is clear that we might not ever see global warming, the apocalyptic scenario is that when I need a new hip in 20 years I'll die from a routine infection because we've run out of antibiotics', said the Chief Medical Officer for England, Dame Sally Davies, in 2013.

Antimicrobial resistance is now a serious threat to public health. As Dame Sally points out, many medical and surgical treatments which we currently take for granted are entirely dependent on our ability to treat infections. Dentistry accounts for up to 10% of total antibiotic prescribing in the UK but how much of this is appropriate?

Anwen Cope and colleagues in Cardiff investigated antimicrobial prescribing by dentists in Wales using clinical audit to examine almost 6,000 prescriptions of antimicrobials to 5,460 patients. The dentists taking part in the study were all sent a summary of SDCEP recommendations: 'Drug prescribing in dentistry'. These guidelines advise that the first step of treatment of acute dental conditions should be local measures (eg exodontia, drainage, and pulpectomy) and that antimicrobials should only be prescribed if these treatments fail to work, or in cases of spreading infection or systemic involvement.

The team compared the real-life prescribing practice with the guidelines to determine the level of compliance. They also provided feedback to practitioners to help them to identify areas where improvement could be made. The audit showed that 31% of patients were prescribed an antibiotic without receiving any local treatment measures, and also found that practitioners were deviating from the recommended doses, frequencies and durations of prescribing in many cases. There were many reasons provided for this practice including time pressures, in addition to patients being unwilling to undergo local treatment or simply demanding antimicrobial prescriptions.

The researchers emphasise that that there is an ongoing need to support dentists to make improvements to their prescribing behaviours.

Further information on antimicrobial resistance in dentistry can be found on the BDA website at www.bda.org/amr

Listen to Stephen Hancocks' summary of this research via the BDJ Youtube Channel http://bit.ly/BDJYouTube

Author Q&A with Anwen Cope Speciality Trainee in Dental Public Health, School of Dentistry, Cardiff University

Did any of the results of this audit surprise you?

One of the most interesting findings of the audit was that in over 40% of cases where an antibiotic was prescribed, there were modifying factors present. Modifying factors include things like patients who declined treatment; clinical time pressures; or patient demand for antibiotics. These are factors that we knew could influence the decision to prescribe, but knowing now how frequently they arise allows us to understand more about consultations in which antibiotics are given.

What else would you like to find out?

Previous studies have shown that clinical audit can improve antibiotic prescribing in primary care dentistry. One of the key steps leading on from this work will be to undertake a re-audit to see if there have been long-term, sustained improvements in prescribing practices amongst dentists who took part. This will hopefully provide an indication of how the audit could be best used to support dentists to use antimicrobials judiciously in their practice.

What do you feel should be the next steps in improving antimicrobial prescribing practice?

The dental profession is taking the threat of antimicrobial resistance seriously, and it's great to see the work being done to implement antimicrobial stewardship programmes across both primary and secondary care dentistry in the UK. One of the best things we can do is start to talk to our patients about how we can conserve the effectiveness of antibiotics for future generations. Everyday prescribing decisions really can make a difference to the spread of resistance, so entering into a conversation with patients about why antibiotics may not be the right treatment for an acute dental condition may reduce patients' expectations of antibiotics further down the line.