Dental antibiotic overuse in Canada post COVID-19


Volume 48-11/12, November/December 2022: Antimicrobial Use and Stewardship


Moving the needle on dental antibiotic overuse in Canada post COVID-19

Susan Sutherland1,2, Karen Born3, Sonica Singhal2,4


1 Sunnybrook Health Sciences Centre, Toronto, ON

2 Faculty of Dentistry, University of Toronto, Toronto, ON

3 Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON

4 Health Promotion, Chronic Disease, and Injury Prevention, Public Health Ontario, Toronto, ON


Suggested citation

Sutherland S, Born K, Singhal S. Moving the needle on dental antibiotic overuse in Canada post COVID-19. Can Commun Dis Rep 2022;48(11/12):502–5.

Keywords: dental, COVID-19, antibiotic overuse, antimicrobial resistance, antimicrobial stewardship


Antimicrobial resistance due to over-prescribing in health care, including in dentistry, has been acknowledged as one of the top ten threats to global health by the World Health Organization. Dentistry is responsible for approximately 10% of antibiotics prescribed worldwide and research has shown up to 80% of antibiotics prescribed by dentists may be unnecessary. During the early months of the coronavirus disease 2019 pandemic, when dental offices handled only dental emergencies, it is probable that antibiotics were prescribed more readily and for longer duration to defer treatment for non-urgent cases. These unprecedented times strengthened the realization that strong dental antimicrobial stewardship practises are required in Canada to keep antimicrobial overuse under control. In countries, such as the United Kingdom and Australia, significant work is ongoing in this regard. Canada has made progress in developing tools for antimicrobial stewardship specifically for physicians in community settings, where the vast majority of antibiotics are prescribed, and it is now time to pay attention to antimicrobial stewardship in the field of dental care. Investments in developing a national level dental prescription database, along with monitoring, education and feedback mechanisms, can strongly support moving the needle on dentist-driven antibiotic overuse in Canada.


At the G7 Health Ministers meeting in Berlin in May 2022, antimicrobial resistance was listed as one of four priority areas of focus, along with coronavirus disease 2019 (COVID-19), future pandemic preparedness and health risks from climate change Footnote 1. Antibiotics are essential to the practice of dentistry for the prevention of distant site infections such as infectious endocarditis, as adjuncts for the prevention of some surgical site infections, and for the treatment of serious odontogenic infections.

Globally, dentistry is responsible for approximately 10% of antibiotics prescribed across health care, and research has shown up to 80% of dental antibiotics may be unnecessary, with wide variation between countries Footnote 2. Reliable information on prescribing by dentists is not available in most Canadian provinces, but data from the BC PharmaNet database indicates that during a ten-year period, antibiotic prescriptions by physicians decreased by 18.2%, while prescriptions by dentists increased by 62.2% Footnote 3. The reasons for this are unclear, but self-reported data from a 2016 survey of Canadian dentists Footnote 4 indicated that there is misunderstanding by dentists of both the medical indications as well as the dental procedures requiring antibiotic prophylaxis for the prevention of infective endocarditis. A lack of awareness of changes to antibiotic guidelines for patients with total joint replacement, variation in prescribing practices among dentists for antibiotic prophylaxis for the prevention of surgical site infections, use of antibiotics for conditions where antibiotics are not necessary and general overuse of clindamycin and underuse of penicillin V. Furthermore, where the most appropriate management of dental infections (surgical intervention) is most likely unavailable, visits to family physicians and emergency departments for non-traumatic dental conditions Footnote 5, may result in inappropriate antibiotic prescribing.

The COVID-19 pandemic has had a profound impact on oral health and dental practices worldwide. Deferred care during the early months of the pandemic created a huge backlog of needed dental treatment. During the months of virtual triage or office closures, with only the most urgent care provided in person, it is not difficult to imagine that when patients presented with dental issues, antibiotics were prescribed more readily and for longer duration. Data from the United Kingdom and Alberta support this Footnote 6 Footnote 7. The contribution of dentist-driven prescription adds to global increase in antibiotic prescribing across health care as a result of the pandemic Footnote 8.

Dental antimicrobial stewardship

The World Dental Federation encourages all national dental associations across all low, middle and high-income economies to commit to antimicrobial stewardship (AMS) by advocating for the inclusion of dentistry in national action plans and supporting their members to prescribe antibiotics wisely Footnote 9 Footnote 10. To date, 58 national dental associations, including the Canadian Dental Association, have taken the World Dental Federation Pledge to tackle antibiotic resistance and enhance patient safety in their countries through three pillars: raising awareness and understanding about the concerns associated through effective communication, education and training; reducing the incidence of dental infection through effective sanitation, hygiene and infection prevention and control measures; and optimizing the use of antibiotics in human health.

Dental AMS programs focus primarily on reducing inappropriate antibiotic prescribing. Whilst reducing the use of antibiotics in dentistry is important, the significance of changes in prescribing rates to patient outcomes is poorly understood Footnote 11. It is important to ascertain that harm to patients is also reduced through the study of patient-related clinical outcomes Footnote 11. From a behavioural sciences perspective, it can be challenging to convince patients and clinicians to avoid an unnecessary antibiotic prescription due to its contribution to antimicrobial resistance. Describing the individual risks and benefits of an unnecessary antibiotic prescription can help support shared decision-making to avoid unnecessary antibiotic prescribing Footnote 12. To this end, research is underway to develop an international consensus on a core outcome set for dental AMS Footnote 13. At the present time, however, efforts comprise a combination of dissemination of guidelines, educational components for both clinicians and patients, and audit and feedback to improve dental antibiotic prescribing.

Guidelines for appropriate dental antibiotic use have largely focused on prophylaxis of distant site infections such as infective endocarditis and late prosthetic joint infections. These vary significantly by region and there continues to be some controversy Footnote 14. In Canada, the American Heart Association guidelines are followed for prevention of infective endocarditis Footnote 15 and the tripartite consensus statement from the Canadian Dental Association, the Canadian Orthopaedic Association and the Association of Medical Microbiology and Infectious Disease Canada provides solid advice against the use of antibiotics for patients with total joint replacement Footnote 16. Useful guidelines have recently been published by the American Dental Association on the use of antibiotics in the management of dental pain and/or intra-oral swelling Footnote 17.

Educational interventions for dentists are increasingly focused on toolkits, designed using concepts from the behavioural change literature and co-designed with patients. Significant work is ongoing in the United Kingdom and Australia in this regard Footnote 18 Footnote 19 Footnote 20 Footnote 21. Although specific to care delivery in those countries, many of the concepts and tools can be adapted for Canadian dental practice. Similarly, through its Using Antibiotics Wisely campaign, Choosing Wisely Canada has developed excellent tools for physicians and resources for patients, which include a "viral prescription pad" and delayed prescription, alongside educational posters and pamphlets Footnote 22. Opportunities exist to leverage this work in the development of dental AMS strategies.

"Audit and feedback" is used to measure an individual's professional practice, compare it to targets, professional standards or peer performance, and provide feedback to the individual to improve quality of care. It can lead to small but potentially important improvements in professional practice, especially when baseline performance is low, and the feedback is carefully designed and delivered Footnote 23. This method has been shown to improve antibiotic prescribing in Canadian medical practice Footnote 24 and dental antibiotic prescribing in Scotland Footnote 25. Future studies to assess the most impactful design approach to audit and feedback are being planned in medicine Footnote 26 and dentistry Footnote 27. That said, because dental care is privately funded and delivered in Canada, accessibility to dental prescribing data is a challenge.

How can we move the needle forward in Canadian dentistry?

Canadian efforts in dental AMS are nascent, but there is strong interest and support for moving forward Footnote 28. The Canadian dental profession is well positioned to evaluate international dental AMS programs, as well as programs developed in medicine such as Choosing Wisely campaigns, to develop a strategy for a Canadian dental AMS program. Learning from international experiences in the field of dentistry can provide opportunities to implement such strategies in the Canadian context. To help move the needle forward, the authors have received a research grant from the tri-university Manchester-Melbourne-Toronto (MMT) Research Fund June 2022 competition. The funding is for the specific purpose of holding a workshop in Toronto in the fall of 2023, the goal of which will be to develop a strategic framework and action plan for AMS in Canadian dentistry, with international contributions from experienced researchers in the field from Manchester and Melbourne. Engagement with key dental and inter-professional stakeholders and organizations, as well as patients and members of the public, will help to shape this initiative and, we hope, provide momentum for change.


Addressing the significant data gap in dental antibiotic prescribing will be challenging. The likely implementation of the National Dental Care Program, targeting more than six million Canadians, presents an opportunity for establishing a dental prescription database at the national level, which can be routinely monitored to support reviewing the prescription practises of participating dentists across provinces and territories Footnote 29. Lessons learned emerging from the workshop may suggest other processes to explore in this regard. This will also support developing audit processes and feedback strategies to ultimately move the needle forward to optimize antibiotic prescribing practices among Canadian dentists.

Authors' statement

SS — Conception, reviewing literature, analysis of findings, writing manuscript and finalizing

KB — Reviewing the manuscript, providing constructive feedback, and finalizing

SS — Conception, reviewing literature, analysis of findings, writing manuscript and finalizing

The content and view expressed in this article are those of the authors and do not necessarily reflect those of the Government of Canada.

Competing interests

The authors have no competing interests.




The authors have received a research grant from the tri-university Manchester-Melbourne-Toronto (MMT) Research Fund June 2022 competition.


Footnote 1

G7 Germany. G7 Health Ministers Communique, 20 May 2022. Berlin, DE: G7 Germany; 2022.

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Footnote 2

Thompson W, Teoh L, Hubbard CC, Marra F, Patrick DM, Mamun A, Campbell A, Suda KJ. Patterns of dental antibiotic prescribing in 2017: Australia, England, United States, and British Columbia (Canada). Infect Control Hosp Epidemiol 2022;43(2):191–8.

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Footnote 3

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Footnote 4

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Footnote 5

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Footnote 6

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Footnote 7

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Footnote 8

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Footnote 9

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Footnote 10

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Footnote 11

Teoh L, Sloan AJ, McCullough MJ, Thompson W. Measuring Antibiotic Stewardship Programmes and Initiatives: An Umbrella Review in Primary Care Medicine and a Systematic Review of Dentistry. Antibiotics (Basel) 2020;9(9):607.

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Footnote 12

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Footnote 13

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Footnote 14

Goff DA, Mangino JE, Glassman AH, Goff D, Larsen P, Scheetz R. Review of Guidelines for Dental Antibiotic Prophylaxis for Prevention of Endocarditis and Prosthetic Joint Infections and Need for Dental Stewardship. Clin Infect Dis 2020;71(2):455–62.

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Footnote 15

Wilson WR, Gewitz M, Lockhart PB, Bolger AF, DeSimone DC, Kazi DS, Couper DJ, Beaton A, Kilmartin C, Miro JM, Sable C, Jackson MA, Baddour LM; American Heart Association Young Hearts Rheumatic Fever, Endocarditis and Kawasaki Disease Committee of the Council on Lifelong Congenital Heart Disease and Heart Health in the Young; Council on Cardiovascular and Stroke Nursing; and the Council on Quality of Care and Outcomes Research. Prevention of Viridans Group Streptococcal Infective Endocarditis: A Scientific Statement From the American Heart Association. Circulation 2021;143(20):e963–78.

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Footnote 16

Canadian Dental Association. Consensus Statement: Dental Patients with Total Joint Replacement. Ottawa, ON: CDA; 2016.

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Footnote 17

Lockhart PB, Tampi MP, Abt E, Aminoshariae A, Durkin MJ, Fouad AF, Gopal P, Hatten BW, Kennedy E, Lang MS, Patton LL, Paumier T, Suda KJ, Pilcher L, Urquhart O, O’Brien KK, Carrasco-Labra A. Evidence-based clinical practice guideline on antibiotic use for the urgent management of pulpal- and periapical-related dental pain and intraoral swelling: A report from the American Dental Association. J Am Dent Assoc 2019;150(11):906–921.e12.

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Footnote 18

Teoh L, Stewart K, Marino RJ, McCullough MJ. Perceptions, attitudes and factors that influence prescribing by general dentists in Australia: A qualitative study. J Oral Pathol Med 2019;48(7):647–54.

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Footnote 19

Teoh L, Stewart K, Marino RJ, McCullough MJ. Improvement of dental prescribing practices using education and a prescribing tool: A pilot intervention study. Br J Clin Pharmacol 2021;87(1):152–62.

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Footnote 20

Thompson W, Tonkin-Crine S, Pavitt SH, McEachan RR, Douglas GV, Aggarwal VR, Sandoe JA. Factors associated with antibiotic prescribing for adults with acute conditions: an umbrella review across primary care and a systematic review focusing on primary dental care. J Antimicrob Chemother 2019;74(8):2139–52.

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Footnote 21

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(11):1345.

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Footnote 22

Leis JA, Born KB, Ostrow O, Moser A, Grill A. Prescriber-led practice changes that can bolster antimicrobial stewardship in community health care settings. Can Commun Dis Rep 2020;46(1):1–5.

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Footnote 23

Ivers N, Jamtvedt G, Flottorp S, Young JM, Odgaard-Jensen J, French SD, O’Brien MA, Johansen M, Grimshaw J, Oxman AD. Audit and feedback: effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev 2012;6(6):CD000259.

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Footnote 24

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Footnote 25

Elouafkaoui P, Young L, Newlands R, Duncan EM, Elders A, Clarkson JE, Ramsay CR; Translation Research in a Dental Setting (TRiaDS) Research Methodology Group. An Audit and Feedback Intervention for Reducing Antibiotic Prescribing in General Dental Practice: The RAPiD Cluster Randomised Controlled Trial. PLoS Med 2016;13(8):e1002115.

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Footnote 26

Shuldiner J, Schwartz KL, Langford BJ, Ivers NM; Ontario Healthcare Implementation Laboratory study team. Optimizing responsiveness to feedback about antibiotic prescribing in primary care: protocol for two interrelated randomized implementation trials with embedded process evaluations. Implement Sci 2022;17(1):17.

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Footnote 27

Goulao B, Scott C, Black I, Clarkson J, McArthur L, Ramsay C, Young L, Duncan E. Audit and feedback with or without training in-practice targeting antibiotic prescribing (TiPTAP): a study protocol of a cluster randomised trial in dental primary care. Implement Sci 2021;16(1):32.

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Footnote 28

Office of the Chief Dental Officer. Canada’s oral health professionals and antimicrobial stewardship. Can Commun Dis Rep 2020;46(11-12):376–9.

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Footnote 29

Singhal S, Quinonez C. 7 principles to guide a national dental care program in Canada. The Conversation. May 2, 2022.

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