Clinician- and patient-factors influencing treatment decisions: Ethnographic study of antibiotic prescribing and operative procedures in out-of-hours and general dental practices

Operative treatment is indicated for most toothache/dental abscesses, yet antibiotics are often prescribed instead of procedures. 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 healthcare 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 influencedwere important for both dentists and patients. Dentist-factors included beliefs about the life-time impact of urgent dental procedures on patients. Patient-factors included 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.