Dentists have an important role to play in tackling the major health system challenges related to overuse.

Dr. Susan Sutherland is Chief of Dentistry at Sunnybrook Health Sciences Centre and President of the Canadian Association of Hospital Dentists. Dr. Sutherland has been leading efforts to start a conversation about overuse both among dental professionals and with patients about unnecessary tests and treatments.

Choosing Wisely Canada: Tell me a bit about the problem of overuse in dentistry.

Susan Sutherland: The Canadian Association of Hospital Dentists Choosing Wisely list was released in April 2018 and includes recommendations that address several common areas of overuse in dentistry. The recommendations cover unnecessary x-rays and imaging in dentistry, replacing fillings unnecessarily and overuse use of medications such as antibiotics and prescription opioids.

For imaging, we wanted to make the point that imaging should not be used instead of taking a good history and clinical exam. That being said, it can be challenging to convince patients that imaging is not necessary. Much dental disease, like cavities, do not become apparent until they are more advanced and can require more advanced treatment. But still, the list highlights that the decision to image should be done after considering the patients’ medical history, oral hygiene and other factors (like xerostomia, which is chronic dry mouth from disease or medication).

The list also highlights a common area of overtreatment in dentistry which is the misconception that old or silver fillings need to be replaced with the more modern white fillings. These newer fillings don’t last as long and every time a filling is replaced, more of the tooth structure is damaged.

Finally, five of the lists’ eight recommendations address commonly overprescribed medications by dentists. There are four recommendations related specifically to antibiotics. We know that over 90% of antibiotic prescriptions are made in the community setting, and at least half of these are unnecessary. Dentists are responsible for a significant portion of these and the recommendations highlight where antibiotics are commonly overused such as for toothaches which are not related to bacterial infections. An important recommendation on our list highlights that dentists should not prescribe opioids for post-surgical pain unless other options have been considered.

CWC: What motivated you to get engaged in Choosing Wisely Canada?

SS: My colleagues and I at the Canadian Association for Hospital Dentists work closely with our physician colleagues. We were impressed with the simplicity and impact of the campaign in other areas of health care and wanted to get involved. At that time, no other dental societies in Canada were working on lists of recommendations. In fact, the only other group of dentists in the world that we are aware of with a Choosing Wisely list of recommendations is the American Dental Association.

Our association felt that we could make a contribution to the campaign and hopefully lead the way for more of our dental colleagues and societies to become involved.

 CWC: How are you getting your dentist colleagues interested in the campaign?

SS: We have been working on a few fronts to get the word out about the list of recommendations, and more generally about Choosing Wisely Canada to dentists. Articles have been published in two widely read dental publications in Ontario and Canada. Dr. Wendy Levinson is a keynote speaker at the 2019 meeting of the Canadian Association of Hospital Dentists. Alongside colleagues from the UK, I will be presenting at an antimicrobial stewardship symposium at the 2019 International Association of Dental Research meeting in Vancouver. The focus of my presentation is on Choosing Wisely Canada and the role it plays in promoting appropriate use of antibiotics.

CWC: Are there specific areas of overuse where you think dentists can make a major impact?

SS: Community dentists often work in isolation from our physician colleagues. Because of this autonomy, I believe it’s important for our profession to lead efforts in tackling some of these major public health issues related to overuse of antibiotics and opioids.

Dentists are responsible for about 10% of all antibiotic prescriptions in Canada, some of which is unnecessary. Our recommendations focus on some of the areas where antibiotics are commonly overused in dentistry.

As for opioids, we know that many young people have their first exposure to opioids either after a prescription for a sports injury or and after wisdom teeth removal. Amy Ma, patient and public advisor for Choosing Wisely Canada has teenaged children and was concerned about an opioid prescribed to her son after wisdom tooth removal.

She and I wrote an editorial about the harms of unnecessary opioid prescriptions after wisdom tooth removal, based on her sons’ experiences. This was widely read and commented on by the public. We then worked with the Institute for Safer Medication Practices (ISMP) Canada to create a patient handout on alternatives to opioids after wisdom teeth removal, and questions to ask about whether that opioid prescription was necessary.

Working with Choosing Wisely has led to other collaborations in these two important areas – with the University of Waterloo Faculty of Pharmacy to develop an online course on Antimicrobial Stewardship  for primary care providers, including dentists, We are also working  with the Royal College of Dental Surgeons of Ontario, Public Health Ontario and others in this regard. Getting the message about Choosing Wisely Canada out in multiple ways to dentists, trainees and the public will have impact and our list has been a catalyst to start these conversations within our profession and beyond.