Objectives Dentistry is a significant contributor to the burden of antimicrobial overprescribing and hence to the global problem of antimicrobial resistance. However, antimicrobial stewardship in Canadian dentistry is nascent, with an acknowledged need for research and coordinated stewardship efforts. This study aimed to gain insights into the perspectives of Canadian dentistry sector leaders and experts on the main drivers of dental antibiotic overprescribing and potential stewardship strategies. Methods Exploratory qualitative design. Data collection: four one-time, 1 h focus group discussions with 22 experts and stakeholders in antimicrobial stewardship in Canada, recruited through a mix of purposive and snowball sampling. Data analysis: inductive thematic analysis. Results The analysis yielded five themes: outdated patterns; antimicrobials as a Band-Aid; fear and risk aversion; behavioural change; and why reinvent the wheel? Overprescription in dentistry stems primarily from a perpetuation of outdated prescribing patterns, ubiquitous use of antibiotics as a temporary solution, and an overly cautious antibiotic use by risk-averse providers. Stewardship strategies should be grounded on behavioural change (motivation, robust data and enactment of new behaviours) and may be modelled after tested medical interventions. Conclusions This study presents a roadmap for behavioural change in dental antibiotic prescribing, and points to the fact that the success of a stewardship actionable plan for Canadian dentistry may depend more on concerted efforts for change than on the creation of novel strategies. Hence, contextualizing and testing medical stewardship programmes in Canadian dentistry may be effective in combatting antibiotic overprescription, thereby contributing to global efforts to reduce antimicrobial resistance.

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.

L'Organisation mondiale de la Santé a reconnu que la résistance aux antimicrobiens, due à la surprescription dans le secteur des soins de santé, y compris en dentisterie, était l'une des dix principales menaces pour la santé mondiale.La dentisterie est responsable d'environ 10 % des antibiotiques prescrits dans le monde et des recherches ont montré que jusqu'à 80 % des antibiotiques prescrits par les dentistes pourraient être non justifiés.Au cours des premiers mois de la pandémie de maladie à coronavirus 2019, lorsque les cabinets dentaires ne traitaient que les urgences dentaires, il est probable que les antibiotiques étaient prescrits plus facilement et pour une plus longue durée afin de différer le traitement des cas non urgents.Cette période sans précédent a renforcé la prise de conscience que de solides pratiques de l'intendance des antimicrobiens dentaires sont nécessaires au Canada pour maîtriser la surutilisation des antimicrobiens.Dans des pays comme le Royaume-Uni et l'Australie, des travaux importants sont en cours à cet égard.Le Canada a fait des progrès dans l'élaboration d'outils d'intendance des antimicrobiens destinés spécifiquement aux médecins en milieu communautaire, où la grande majorité des antibiotiques sont prescrits, et il est maintenant temps de s'intéresser à l'intendance des antimicrobiens dans le domaine des soins dentaires.Les investissements dans l'élaboration d'une base de données nationale sur les ordonnances dentaires, ainsi que les mécanismes de surveillance, d'éducation et de rétroaction, peuvent fortement contribuer à faire avancer la lutte contre la surconsommation d'antibiotiques par les dentistes au Canada.

Purpose: Although recent evidence has suggested the value of operative therapy for the management of medication-related osteonecrosis of the jaw (MRONJ), its effectiveness remains controversial. The purpose of this study was to measure and compare MRONJ disease resolution and changes to the quality of life (QoL) between operative and nonoperative management of MRONJ. Methods: This is a prospective cohort study. Consecutive MRONJ patients presenting to Mount Sinai Hospital and Sunnybrook Health Sciences Center (September 2016 to August 2020) were recruited and divided by the treatments provided into operative and nonoperative groups. The primary and secondary outcome variables were disease resolution and QoL at 6 months, respectively. Disease resolution was defined as mucosal coverage with an absence of pain, and QoL was measured via the MRONJ-QoL questionnaire. The primary and secondary outcomes, after adjusting for potential confounders, were assessed via multivariate logistic regression and multivariate linear regression analyses, respectively, with significance set to P < .05. Results: Sixty patients were included in this study. Of these, 40 patients received operative treatment, and 20 received nonoperative treatment. In the unadjusted analyses, operative therapy was found to be significantly associated with both disease resolution and improvement in QoL (relative risk 6.75, 95% confidence interval [CI] 1.78 to 25.6, P < .001; and MRONJ-QoL score improvement of 3.35, 95% CI 0.16 to 6.54, P = .04). When controlling for potential confounders, operative therapy was found to be significantly associated with disease resolution when compared with nonoperative therapy (adjusted odds ratio 46.2, 95% CI 5.57 to 383.9, P < .001). Linear regression analysis also showed operative therapy to be significantly associated with improved QoL compared with nonoperative therapy (adjusted MRONJ-QoL score improvement of 3.72, 95% CI 0.34 to 7.11, P = .03). Conclusions: Our study demonstrated operative therapy to be significantly associated with disease resolution and improvement in QoL. (C) 2022 American Association of Oral and Maxillofacial Surgeons

Background. Although the overall rate of antibiotic prescribing has been declining in British Columbia, Canada, the authors conducted a study to explain the increased rate of prescribing by dentists.Methods. The authors obtained anonymized, line-listed data on outpatient prescriptions from 1996 to 2013 from a centralized, population-based prescription database, including a variable coding prescriber licensing body. Analyses used Anatomical Therapeutic Classification standard codes and defined daily dose (DDD) values. The authors normalized prescribing rates to the population and expressed the rates in DDDs per 1,000 inhabitants per day (DID). The Canadian Dental Association released a webinar that invited correspondence from dentists about the drivers of the trend.Results. From 1996 to 2013, overall antibiotic use declined from 18.24 DID to 15.91 DID, and physician prescribing declined 18.2%, from 17.25 DID to 14.11 DID. However, dental prescribing increased 62.2%, from 0.98 DID to 1.59 DID, and its proportionate contribution increased from 6.7% to 11.3% of antibiotic prescriptions. The rate of prescribing increased the most for dental patients 60 years or older. Communication from dentists in Canada and the United States identified the following explanatory themes: unnecessary prescriptions for periapical abscess and irreversible pulpitis; increased prescribing associated with dental implants and their complications; slow adoption of guidelines calling for less perioperative antibiotic coverage for patients with valvular heart disease and prosthetic joints; emphasis on cosmetic practices reducing the surgical skill set of average dentists; underinsurance practices driving antibiotics to be a substitute for surgery; the aging population; and more dental registrants per capita.Conclusions. Emerging themes for dental prescribing should be explored further in future studies; however, themes already identified may guide priorities in antibiotic stewardship for continuing dental education sessions.Practical Implications. Antibiotic prescribing should be reviewed to make sure that we are compliant with guidelines. Most practitioners will find opportunities to prescribe less often and for shorter durations.

The complex care required to address the needs of head and neck cancer patients requires interprofessional collaboration. Using the compelling narrative of a patient's journey through cancer treatment in the Canadian setting, the aim of this study was to engage health professions students to discover the importance of interprofessional care for complex patients, while delivering content on head and neck cancer care and providing training/experience in interprofessional education (IPE) facilitation to clinicians. In the study, 38 students from nine health disciplines participated in a three-hour workshop that included interactive presentations and facilitated small- and large-group activities. The Interdisciplinary Education Perception Scale (IEPS) was administered pre and post workshop to examine changes in students' attitudes and perceptions about IPE. Qualitative participant and facilitator feedback regarding the session was obtained using a structured questionnaire and debriefing sessions with each group. An overall improvement of scores on the IEPS was observed, while analyses of individual items showed improved scores on all items but one. Session feedback from students and facilitators was positive. The results suggest that combining case-based methods with interprofessional learning in the clinical setting allowed students to develop an appreciation for the complex needs of head and neck cancer patients and the need for collaboration to improve patient outcomes.

Clinical practice guidelines are a pre-appraised source of the best available evidence on a particular clinical topic. They are not designed to replace clinical judgment or usurp clinicians’ autonomy. Rather, the clinician is expected to take into account each patient’s history and preferences, together with their clinical judgment, when applying a guideline. This article outlines the organizational structure and the methodology used by a clinical practice guideline development group. We discuss both advantages and disadvantages of guidelines, and outline some of the present barriers to their implementation. The Canadian Collaboration on Clinical Practice Guidelines in Dentistry produce guidelines on issues of oral health. These guidelines are based on systematic reviews of clinical research and validated through consensus of content experts and clinicians.

Cardiopulmonary bypass (CPB) is an immuno-reactive state where neutrophils are activated and accumulate in different tissues. Edema and tissue necrosis are the most common sequelae observed, predominantly in the lungs, kidneys, and heart, heralding significant risk for postoperative complications. No method exists to noninvasively assess in vivo neutrophil activity. The objective of this study was to determine if neutrophil recruitment to the oral cavity would correlate with specific biomarkers after coronary bypass surgery (CPB).

PURPOSE:To evaluate the effect of continuing warfarin therapy on the bleeding risk of patients undergoing elective dental surgical procedures. METHODS:Data sources were the MEDLINE and EMBASE databases, the Cochrane Central Register of Controlled Trials, a manual citation review of the relevant literature, content experts and relevant abstracts from the proceedings of the International Association for Dental Research. Study selection was carried out independently by 2 reviewers, as was quality assessment. Data extraction was done by 3 reviewers. Differences were resolved by consensus. Eligible studies were randomized controlled trials that compared the effects of continuing the regular dose of warfarin therapy with the effects of discontinuing or modifying the dose on the incidence of bleeding in patients undergoing dental procedures. RESULTS:Five trials (a total of 553 patients) met the inclusion criteria. Compared with interrupting warfarin therapy (either partial or complete), perioperative continuation of warfarin with patients" usual dose was not associated with an increased risk for clinically significant nonmajor bleeding (relative risk [RR], 0.71; 95% confidence interval [CI]: 0.39-1.28; p = 0.65; I2 = 0%) or an increased risk for minor bleeding (RR, 1.19; 95% CI: 0.90-1.58; p = 0.22; I2 = 0%). CONCLUSIONS:Continuing the regular dose of warfarin therapy does not seem to confer an increased risk of bleeding compared with discontinuing or modifying the warfarin dose for patients undergoing minor dental procedures.

Domestic violence (DV), now a national health concern, has pervasive effects at both the individual and societal levels. Women are the primary victims of DV; their lifetime prevalence has been reported to be 20%-53.8%. The sequelae of violence include increased acute and chronic health care utilization, psychological harm and a wide range of physical injuries. Head and neck injuries are the most common result of violence, and many women seek dental treatment following abuse. Dentists are in a unique position to identify abused victims and intervene. However, they are not well trained to identify victims of DV, and they lack appropriate resources to manage identified victims. Moreover, of the many health professionals surveyed, dentists feel the least responsible for intervening in cases of DV, and interventions by dentists are minimal. Barriers to screening for DV occur at the patient, provider and system levels, but they can be overcome with increased education. DV education, assessment and management should be a priority, so that dentists can help improve the lives of the many women faced with abuse.

Data sources The Cochrane Oral Health Group Trials Register, Cochrane Central Register of Controlled Trials, Medline and Embase were searched to April 2006. Reference lists from relevant articles were scanned and the authors of eligible studies were contacted to identify trials and obtain additional information. Study selection For inclusion, an article had to satisfy the following criteria: document a randomised controlled trial (RCT); participants should be people receiving chemotherapy or radiotherapy treatment for cancer; prescribe agents to prevent oral mucositis; and have the primary outcome of preventing mucositis. Data extraction and synthesis Data were extracted independently and in duplicate. Authors were contacted for details of randomisation and withdrawals and a quality assessment was carried out. For dichotomous outcomes, risk ratios (RR) were calculated using a random-effects model. Results The search identified 202 articles, of which 71 studies had useable data comprising 5217 patients. Of the 29 interventions included in the trials, 10 studies showed some evidence of a weak benefit for preventing or reducing the severity of mucositis. Interventions where more than one trial in the meta-analysis found a significant difference compared with placebo/ no treatment were as follows: amifostine: provided minimal benefit in preventing moderate and severe mucositis (RR, 0.84 and 0.60, respectively); antibiotic paste or pastille: demonstrated moderate benefit in preventing mucositis (RR, 0.87); hydrolytic enzymes: reduced moderate and severe mucositis (RR, 0.52 and 0.17, respectively); and ice chips: prevented mucositis at all levels (RR, 0.63, 0.43 and 0.27). Other interventions showing some benefit in only one study were benzydamine, calcium phosphate, honey, oral care protocols, povidone and zinc sulphate. Conclusions Several of the interventions were found to have some benefit at preventing or reducing the severity of mucositis associated with cancer treatment. The strength of the evidence was variable and implications for practice include consideration that benefits may be specific for certain cancer types and treatment. There is a need for well-designed RCT with sufficient numbers of participants to perform subgroup analyses by type of disease and chemotherapeutic agent.

Cochrane Oral Health Group Trials Register and the Pain, Palliative Care and Supportive Care Group Trials Register, the Cochrane Central Register of Controlled Trials, Medline and Embase. Randomised controlled trials (RCT) were included that involved patients over the age of 18 years who had presented with a single tooth with a clinical diagnosis of irreversible pulpitis. Abstracts of studies were independently assessed by two reviewers. The primary outcome was patient-reported pain (intensity/duration) and pain relief measured on a categorical scale in the preoperative phase of irreversible pulpitis. Secondary outcomes were type, dose and frequency of medication required for pain relief. Only one trial was included so pooling of data from studies was not possible and a descriptive summary is presented. One trial of 40 participants was included. There was a close parallel distribution of the pain ratings in both the intervention and placebo groups over the 7-day study period. The between-group differences in sum pain intensity differences for the penicillin group were 6.0±10.5, and for placebo 6.0±9.5 (P=0.776; differences assessed by Mann–Whitney–Wilcoxon test considered to be statistically significant at P=0.05). The sum pain percussion intensity differences for the penicillin group were 3.5±7.5 and placebo 2.0±7.0 (P=0.290). There was no significant difference in the mean total number of ibupro-fen tablets (P=0.839) and acetaminophen tablets (P=0.325) taken for pain relief in either group over the study period. The administration of penicillin over placebo did not appear to significantly reduce the quantity of analgesic medication taken (P=0.05) for irreversible pulpitis. This review based on one methodologically sound but low-powered small sample trial, provides some evidence that there is no significant difference in pain relief between individuals who had untreated irreversible pulpitis who did or did not take antibiotics in addition to analgesics.

Safety leading indicators have been investigated as a proactive management approach to managing construction safety. However, there is a lack of insight into the implementation of safety leading indicators in construction projects and organizations. This causes difficulties in the adoption and consistent use of safety leading indicators in the construction industry. The aim of the research is to explore what and how safety leading indicators can be implemented to improve safety management in the construction industry. Built upon Xu et al. (2021), the study prioritized the relative importance of 17 safety leading indicators through a three-round Delphi survey and voting analytic hierarchy process (VAHP). It was found that organization commitment; client, designer and contractor engagement; training and orientation; safety climate and competence were most critical to safety performance in construction. Furthermore, operational, organizational and strategic barriers to the effective implementation of safety leading indicators were identified through the focus group discussion. The study suggested strategies for addressing these barriers and moving toward a proactive safety management approach. This study contributes to the theories and practices of construction safety management by linking the deployment of safety leading indicators with organizational and strategic issues at firm and project levels and addressing the root causes of poor performance. The effective deployment of safety leading indicators needs the engagement of clients, contractors, designers and supply chains to develop organizational capabilities to drive improvements from the project front-end to completion.

BACKGROUND:High-quality systematic reviews are the basis of valid, reliable clinical practice guidelines, or CPGs. In 1999, a Canadian collaboration of dentists embarked on the process of developing guidelines.METHODS:The Canadian Collaboration on Clinical Practice Guidelines in Dentistry, or CCCD, is a coalition of multiple stakeholders from organized dentistry and academia whose mandate is to develop CPGs for practicing dentists. In the development of the first CPG based on a systematic review of the literature, the CCCD Methodology Resource Group (of which the authors were co-chairs) gained some valuable insights. The authors wrote this article to share their experiences and lessons learned and to offer practical advice to others who may undertake similar projects.RESULTS:The authors identify a number of methodological issues and logistical problems and make suggestions for effective management of the review and guideline development processes.CONCLUSIONS AND PRACTICE IMPLICATIONS:Systematic reviews and the development of CPGs require rigorous methodology, as well as input from content experts and clinicians, to ensure validity and relevance. The processes are costly and time-intensive, but the anticipated outcome is enhanced clinical decision making and improved oral health.

OBJECTIVE To perform a systematic literature review and meta-analysis on the effectiveness of interventions used in the management of acute apical abscess in the permanent dentition. METHODS Electronic databases were searched from their inception to March 2002. These searches, combined with manual searching, yielded 85 citations, of which 35 were relevant. Independent application of inclusion criteria by 3 reviewers yielded 8 eligible randomized controlled studies. Data on population, interventions, outcomes (reduction of pain or swelling or both, as reported by patients or clinicians) and methodological quality were determined by independent triplicate review. Disagreements were resolved by consensus. RESULTS All papers included in the meta-analysis compared an antibiotic with an active control, a placebo or no pharmacotherapy as an adjunct for patients who had received concomitant therapy (i.e., incision and drainage, endodontic therapy or extraction). The 8 trials were randomized; in 3 of these, the method of randomization was described and appropriate. Five studies were double-blinded, and 2 of these described the method of blinding. Four trials described withdrawals, but none included an intention-to-treat analysis. Six studies compared 2 antibiotics. For the outcomes "absence of infection"and "absence of pain" the pooled odds ratios (ORs) were not statistically significant; for the outcome "absence of pain and infection," 3 studies showed an equivalent treatment effect in both treatment and control groups. One open-label study (with a quality score of 2) showed a result favouring azithromycin over co-amoxiclav (OR 0.58, 95% confidence interval 0.35-0.96). Two studies compared adjunctive antibiotic therapy with placebo; no benefit to patients was demonstrated with this intervention. CONCLUSIONS In the management of localized acute apical abscess in the permanent dentition, the abscess should be drained through a pulpectomy or incision and drainage. This analysis indicated that antibiotics are of no additional benefit. In the event of systemic complications (e.g., fever, lymphadenopathy or cellulitis), or for an immunocompromised patient, antibiotics may be prescribed in addition to drainage of the tooth.

The ability to conduct efficient literature searches is fundamental to the practice of evidence-based dentistry. In the second part of this series on evidence-based dentistry, strategic literature search techniques are discussed. MEDLINE, because of its breadth, depth and continuous maintenance by the U.S. National Library of Medicine (NLM), is the best source of evidence for health care. Although there are many gateways to MEDLINE, this paper highlights the user-friendly versions of MEDLINE offered free on the Internet by the NLM. The use of well-established search tactics and the unique features of the NLM sites facilitate rapid, effective literature searches.

Evidence-based dentistry involves defining a question focused on a patient-related problem and searching for reliable evidence to provide an answer. Once potential evidence has been found, it is necessary to determine whether the information is credible and whether it is useful in your practice by using the techniques of critical appraisal. In this paper, the fifth in a 6-part series on evidence-based dentistry, a framework is described which provides a series of questions to help the reader assess both the validity and applicability of an article related to questions of therapy or prevention.