Clinician and Patient Factors Influencing Treatment Decisions: Ethnographic Study of Antibiotic Prescribing and Operative Procedures in Out-of-Hours and General Dental Practices

Abstract

Operative treatment is indicated for most toothache/dental abscesses, yet antibiotics instead of procedures are often prescribed. This ethnographic study aimed to identify clinician and patient factors influencing urgent dental care for adults during actual appointments; and to identify elements sensitive to context. Appointments were observed in out-of-hours and general dental practices. Follow-up interviews took place with dentists, dental nurses, and patients. Dentist and patient factors were identified through thematic analysis of observation records and appointment/interview transcripts. Dentist factors were based on a published list of factors influencing antibiotic prescribing for adults with acute conditions across primary health care and presented within the Capability-Opportunity-Motivation-Behaviour model. Contextually sensitive elements were revealed by comparing the factors between settings. In total, thirty-one dentist factors and nineteen patient factors were identified. Beliefs about antibiotics, goals for the appointment and access to dental services were important for both dentists and patients. Dentist factors included beliefs about the lifetime impact of urgent dental procedures on patients. Patient factors included their communication and negotiation skills. Contextual elements included dentists’ concerns about inflicting pain on regular patients in general dental practice; and patients’ difficulties accessing care to complete temporary treatment provided out of hours. This improved understanding of factors influencing shared decisions about treatments presents significant opportunity for new, evidence-based, contextually sensitive antibiotic stewardship interventions.

Factors, Perceptions and Beliefs Associated with Inappropriate Antibiotic Prescribing in German Primary Dental Care: A Qualitative Study

“…Over-caution towards medically compromised patients and in cases of unclear diagnoses was described [ 6 , 7 , 24 , 37 , 38 ]. An ethnographic study stated, in line with our results, that dentists fear the risk of spreading dental infections [ 31 ]. Chate et al found the largest significant post-audit prescription reductions for ‘patient expectation’, ‘pressure of time and workload’ and ‘uncertainty in the diagnosis’ [ 18 ].…”

“…While questionnaire and register data on antibiotic prescribing in dentistry have been obtained over the last two decades, high-standard qualitative research has been brought forward only recently [ 31 , 32 , 33 , 34 ]. Most available data up to our investigation derived as secondary objective from feedback and audit or from educational interventions [ 18 , 19 , 20 , 24 , 26 , 36 ].…”

“…Thompson et al have highlighted that dental practices are generally run as private businesses and are therefore reliant on nurturing relationships. In their data, dentists also described the conflict of financial burdens for patients resulting from definitive treatment [ 31 ]. In contrast to other findings, affordability of definitive treatment was not a concern of the dentists interviewed in our study [ 35 , 40 ].…”

“…In addition to that, they found factors that were specific to dentistry—namely, ‘procedure possible’ and ‘treatment skills’ [ 30 ]. In an ethnographic study, Thompson et al were further able to identify never reported aspects, namely awareness of potential adverse outcomes from antibiotic use, beliefs abouts risks of antibiotics and the importance of responsible use and the accountability for dentists’ patterns of prescribing [ 31 ]. This might indicate that a certain shift might already be taking place in dentists’ attitudes towards antibiotics.…”

“…Barriers and facilitators should be precisely addressed. Yet, only few qualitative studies aiming at understanding dentists’ views towards antibiotics have been conducted [ 30 , 31 , 32 , 33 , 34 ]. Most insights on possible confounders to irrational prescribing have been acquired within Anglo-American settings, predominately in the UK.…”