Antibiotics are life-saving drugs: when people need antibiotics to treat a life-threatening infection, they need these antibiotics to work for them. Infections that don’t respond to antibiotics are known as antibiotic-resistant infections. One of the most important ways that these infections develop and spread is repeated exposure to antibiotics. Prescribing antibiotics for dental problems contributes significantly to the burden of antibiotic use.
FDI World Dental Federation sat down with Dr Wendy Thompson, a dentist by profession and a leading advocate for the safe and responsible use of antibiotics. Dr Thompson lectures around the world to raise awareness on antibiotic resistance and encourages tailored, context-specific responses to combat it. She is also the lead author of FDI’s imminent white paper on the essential role of the dental team in reducing antibiotic resistance.
Do you think that most dentists know about antibiotic resistance and how they might be contributing to it?
Studies around the world have shown that most dentists know about antibiotic resistance, but they don’t always think that they are the ones who are responsible for it. And it isn’t just dentists who think that – most clinicians from different disciplines respond that way when they are asked the same question. Actually, we all need to take responsibility for antibiotic resistance and for tackling it.
I think that dentists are aware of the problem for society, but I think there’s something more to be done about personalizing it and recognizing the risks for their own patients. By exposing your patients to antibiotics, you’re driving changes in that patient that can make them less healthy. Antibiotics affect the body’s microbiome – the balance between the good bacteria and the bad ones.
If a patient comes to you with a dental infection, and that infection is resistant already, then the antibiotics you give them won’t work. If that infection carries on going, it can turn into a life-threatening condition, like Ludwig’s angina, or sepsis. Without effective antibiotics we know that these conditions often aren’t survivable. So if we give our patients antibiotics that aren’t necessary, then they might not work when they are necessary.
I’ve heard dentists say that certain patients “demand” antibiotics, even when they are not necessarily indicated. What are some strategies that dentists can use to manage this?
There’s a whole range of different ways of tackling what is perceived to be a demand. In the new FDI white paper, we’ll be providing a range of examples that clinicians can use and see what would work for them in their own context.
My doctoral research about antibiotic use during urgent dental care showed that there are patients who demand antibiotics. The reasons for demanding (or appearing to be demanding) can be quite different—so it’s about understanding where the patient’s coming from in order to address their particular concern. One patient in my doctoral research study was trying very, very hard to negotiate antibiotics from the dentist, because he’d had them before and they had allowed him to keep his tooth for longer—to delay the extraction. The dentist just held her line and said, “No. Antibiotics aren’t right for you. They will not fix your problem and will put you at more risk.” What was interesting is that he actually declined all treatment offered on that day. But then he came back the following day after he’d thought about it and had the tooth taken out. Now that outcome needed a really strong line from that dentist. She was really confident in her position and also trusted that her colleagues would support her if anything happened, like if the patient complained afterwards.
Antibiotic stewardship is more than just about dentists not prescribing. When people need antibiotics, they do need them. So this is about getting the balance right in order to optimize prescribing. It’s about dentists having the skills to diagnose acute conditions accurately and having the confidence, where appropriate, to say, “At the moment you really don’t need antibiotics, but if your body temperature goes up, or you get swelling that’s moving towards closing your airway or eye, then you might need antibiotics. You should come back and see me under those circumstances.”
How do you think we can optimize dental prescribing of antibiotics globally?
Globally, we need to support dental organizations and teams first to understand their problem, so they can develop their own solutions. The white paper is about providing a broad framework, which sets out the wider strategic context for why antibiotic resistance is a big problem and why dentists need to play a part in tackling it. The goal of the white paper is to help different teams, countries, and individuals around the world find the right solution in their own context.
We also need to be careful not to impose evidence-based guidelines developed using evidence from high-income countries on low- and middle-income countries without checking that the evidence is pertinent to them. For example, in the UK we’ve got evidence-based guidance that is based on evidence from research that has been undertaken in the UK. So we can be confident that we have the right guidance for us in the UK. But when I’m working with colleagues in the Philippines, for example, they have a very different context: different access to dentistry, different abilities of patients to pay for care, and different ways of people being able to access antibiotics. So it isn’t about providing one set of guidance. It’s about supporting individual countries, individual organizations, and maybe even individuals to understand their own problems and design their own solutions.
What is the main message you’d like to share with dentists regarding antibiotic resistance and stewardship?
When people need antibiotics, they need them to work. Unnecessary antibiotic use drives antibiotic resistance and puts patients at risk for anaphylaxis, C. difficile infections and other adverse events. By making sure that we don’t expose people unnecessarily to antibiotics, we don’t promote antibiotic-resistant infections developing in that individual or in society more generally—this is how we can protect our patients.
This interview has been edited for length and clarity.