Reducing harm and waste
Dentistry is unique in its need for and use of resources. Running a fully equipped and staffed surgery with specialist equipment and materials demands significant resource. Dental professionals can be stewards of these resources, ensuring they are used appropriately, to reduce harm and waste and contribute to sustainability of the healthcare system.
We want to do the best for the people we care for. This conscientiousness can occasionally take the form of overuse of investigations and treatments which may be unnecessary or even harmful. One of the biggest harms is inappropriate prescribing of antibiotics. Dental antibiotic prescribing represents 10% of prescriptions globally, and evidence suggests up to 90% of antibiotic prescribing by dentists in the UK is inappropriate1.
Being mindful of how we use resources will also help us reduce waste. By understanding what people really value, we can ensure our care is impactful. This can be achieved by involving patients more in their care through shared decision making2 and empowering them to make decisions that are right for them. Tools such as BRAN (an acronym for ‘Benefits, Risks, Alternatives, or do Nothing’), promoted by NHS24’s ‘It’s OK to Ask’ national campaign3, can support patients to make informed choices about their care. Evidence shows that when people are involved in decision making, they often choose fewer interventions4, potentially lessening the demand on resources.
Choosing Wisely[EF1] [EF2] methodology5 supports shared decision making through the use of tools such as BRAN, with the aim of reducing unnecessary care. It can aid decision making around treatment choices, such as appropriate recall intervals. Feedback from focus group work exploring patients’ perceptions of different recall intervals has been positive (Figure 1). This research has been conducted as part of a fellowship funded by The Healthcare Improvement Studies (THIS) Institute, led by Dr Heather Cassie at the University of Dundee6.
“If my dentist says my teeth are fine, I don’t have to go every six months, that means I don’t have to take half days off work. I think majority of people will be fine with it.” – Patient 11
Figure 1: patient feedback from focus group work exploring patients’ perceptions of changes to recall intervals
The following case studies are designed to encourage reflection on some of these key issues:
Deliberating on dentures
John, 74, attends his annual check-up. He has hypertension and some mobility issues. He cares for his wife at home and takes multiple buses to attend. On examination, you note that his upper prosthesis is sound, though the lower is moderately unstable, owing to ridge resorption. You recommend a new lower prosthesis to John and fetch a laboratory prescription slip. Through meaningful conversation, John states that being around for his wife is of utmost importance, and he enjoys a satisfying diet. He even states he sometimes doesn’t wear his lower denture at all!
What are the implications for resources and potential sources of waste in providing new prostheses for John? What is it that John really values? Are there any potential harms?
Realistic recall
Jennifer, 48, attends as a new patient. Medically, Jennifer is fit and well, doesn’t smoke, drinks alcohol well within recommended limits, and has a good diet. Jennifer is exceptionally busy professionally. On examination, you note exemplary oral hygiene, with Code 0s during the BPE. You communicate this to Jennifer, who asks if she is getting a scale and polish today – her previous dentist did one every six months! Jennifer doesn’t like them at all but knows they have been part of her care.
What alterations to Jennifer’s treatment regime could you institute to reduce waste? Would six-monthly check-ups and scales be impactful and would they be valued by Jennifer?
Antibiotics and toothache
Umar, 32, attends for an emergency appointment. Umar is fit and well with generally good dental health but has a large restoration in his lower left first molar that was recently placed. You diagnose irreversible pulpitis. Umar is insistent on receiving antibiotics – he wants out of pain! However, there are no indications.
What options do you and Umar have for treatment? What are the implications for resources, and the risks of harm, individually, environmentally, and for public health?
Temporomandibular Disorders (TMD)
Aanshi, 36, attends with jaw pain that worsens with function. Following history and examination, you diagnose myogenous TMD. Aanshi’s friend was seen at hospital with something similar and asks to be sent there.
What is the evidence/guidance on the management of TMD? Can you provide a positive outcome without referring to the busy OMFS unit? Which conversational approaches could support this dialogue with Aanshi?
By being stewards of resources, we can reduce harm and waste. By avoiding unnecessary treatments and prescribing prudently we can lessen the demands on healthcare systems with limited resources. This will promote sustainable care and deliver outcomes that people value.
References
1Thompson W, Teoh L, Hubbard CC, et al. Patterns of dental antibiotic prescribing in 2017: Australia, England, United States, and British Columbia (Canada). Infection Control & Hospital Epidemiology. 2022;43(2):191-198. doi:10.1017/ice.2021.87
2A. L. Cope, N. A. Francis, F. Wood, and I. G. Chestnutt, “Antibiotic Prescribing in UK General Dental Practice: A Cross-Sectional Study,” Community Dentistry and Oral Epidemiology 44 (2016): 145–153.
3The principles in practice series: part 2 – Scottish Dental magazine : Scottish Dental magazine
4It’s OK to Ask | NHS inform
5Realistic Medicine – Shared decision making, reducing harm, waste and tackling unwarranted variation
6Choosing Wisely: Reducing unnecessary care in dental primary care – Discovery – the University of Dundee Research Portal
7http://www.thisinstitute.cam.ac.uk/about/people/dr-heather-cassie/