antibiotics Article Co-Developing an Antibiotic Stewardship Tool for Dentistry: Shared Decision-Making for Adults with Toothache or Infection Wendy Thompson 1,2, * , Jonathan Sandoe 3 , Sue Pavitt 2 , Tanya Walsh 1 and Lucie Byrne-Davis 4   Citation: 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 2021, 10, 1345. https:// doi.org/10.3390/antibiotics10111345 Academic Editor: David Gillespie Received: 17 October 2021 Accepted: 2 November 2021 Published: 4 November 2021 Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affil- iations. Copyright: © 2021 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/). 1 Division of Dentistry, University of Manchester, Manchester M13 9PL, UK; tanya.walsh@manchester.ac.uk 2 School of Dentistry, University of Leeds, Leeds LS2 9JT, UK; S.pavitt@leeds.ac.uk 3 School of Medicine, University of Leeds, Leeds LS1 3EX, UK; j.sandoe@leeds.ac.uk 4 Division of Medical Education, University of Manchester, Manchester M13 9PL, UK; lucie.byrne-davis@manchester.ac.uk * Correspondence: wendy.thompson15@nhs.net; Tel.: +44-7837-190-387 Abstract: Dentistry is responsible for around 10% of antibiotic prescribing across global healthcare, with up to 80% representing inappropriate use. Facilitating shared decision-making has been shown to optimise antibiotic prescribing (antibiotic stewardship) in primary medical care. Our aim was to co-develop a shared decision-making antibiotic stewardship tool for dentistry. Dentists, patients and other stakeholders prioritised factors to include in the new tool, based on previous research (a systematic review and ethnographic study) about dentists’ decision-making during urgent appointments. Candidate behaviour-change techniques were identified using the Behaviour Change Wheel and selected based on suitability for a shared decision-making approach. A ‘think aloud’ study helped fine-tune the tool design and Crystal Marking ensured clarity of messaging. The resulting paper-based worksheet for use at point-of-care incorporated various behaviour change techniques, such as: ’information about (and salience of) health consequences’, ‘prompts and cues’, ‘restructuring the physical (and social) environment’ and ‘credible sources’. The think aloud study confirmed the tool’s acceptability to dentists and patients, and resulted in the title: ‘Step-by-step guide to fixing your toothache.’ Further testing will be necessary to evaluate its efficacy at safely reducing dental antibiotic prescribing during urgent dental appointments in England and, with translation, to other dental contexts globally. Keywords: antibiotic; stewardship; decision making; shared; dental; toothache; infection; primary healthcare; behavioural influences; dental procedures 1. Introduction Antimicrobial resistance is a significant threat to global health, wealth and well-being, and is driven by the use of antibiotics [1]. The World Health Organisation global action plan on tackling antimicrobial resistance, therefore, seeks to optimise the use of antimicro- bials in human and animal health (known as antimicrobial stewardship) [1]. The United Kingdom (UK) Government 20-year vision is for strong antimicrobial stewardship and diagnostic stewardship, by ensuring all decisions are supported by diagnostic tests and decision-support tools [2]. Dentistry accounts for around 10% of antibiotic (antibacterial drug) prescribing across international healthcare, with up to 80% shown to represent over- prescribing [3]. In England’s publicly funded National Health Service (NHS), urgent dental care for people with acute dental pain or infection accounts for most dental antibiotics, with around 90% of them for adults [4]. In 2020, 3.0 million antibiotics were dispensed to dental patients, costing NHS England £7.6M [5]. Unlike in medical settings, where many common infections are amenable to self- care [6], acute dental pain and infection will usually recur without a procedure [7]. As dental infections have the potential to spread rapidly to become life-threatening conditions, all dental surgeons are skilled to diagnose and manage dental pain and infection using Antibiotics 2021, 10, 1345. https://doi.org/10.3390/antibiotics10111345 https://www.mdpi.com/journal/antibiotics