The dental prescriptions that are killing your patients

August 29, 2018

Are your prescribing habits leading to harmful consequences for your patients?

Common dental prescriptions like antibiotics and opioids can have severe harmful consequences for your patients. The American Dental Association’s (ADA) recommendations for both types of drugs have changed based on the latest scientific evidence. While both have their time and place in your practice to maintain a proper standard for patient care, overprescribing in either category can lead to serious conditions for some patients.

Dr. Jennifer Sanders, DMD, has a succinct summary of the dental industry’s stance on prescription medication: “Honestly, most things, like antibiotics and opioids, are overprescribed.” This sentiment is echoed by the literature, the Centers for Disease Control and Prevention (CDC) and the ADA.

Christopher Cook, DMD, is a private practice endodontist in Louisville, Kentucky, who has been practicing since 1995. Earlier in his career, when the literature showed that they were safe, Dr. Cook prescribed opioids, but usually no more than three days’ worth. Today, he estimates that in the last 18 months he has written two prescriptions for opioids. He also explains to his patients why they’re no longer the answer.

“Education, for me, is critical. You have to tell them, ‘Here’s what I am going to ask you to take to make the pain or discomfort go away if you have any pain or discomfort.’ For me, it’s the nonsteroidal anti-inflammatories (Motrin, ibuprofen, Advil). If it’s still hurting, add one over-the-counter Tylenol in between and that should work, and if not I expect a call,” Dr. Cook says.

The dental industry is contributing to the antibiotic overprescribing problem in the U.S. Per the CDC, dentistry as a whole prescribed 24.9 million prescriptions of oral antibiotic prescriptions in 2014.¹ Most, if not all, of these antibiotic prescriptions were for prophylaxis before certain patients’ dental procedures and to treat dental infections.
Dentistry prescribed only 6.4 percent (16.3 million) of the overall opioid prescriptions in 2012, which the CDC reported over 255 million for all health care providers in 2012.² However, since dentists tend to write opioid prescriptions for adolescent patients having their wisdom teeth removed, dentists are usually the first healthcare provider to introduce patients to opioids.

What harm does overprescribing cause?

Overprescribing antibiotics contributes to antibiotic resistance, where the drugs are no longer effective against the bacteria the drug seeks to eliminate. According to the CDC, antibiotic resistance is an urgent threat to public health.³ The bacteria resistant to antibiotics are difficult and expensive to treat. In extreme cases, antibiotic-resistant infections can have serious consequences, such as physical disability and even death. As part of their Be Antibiotics Aware campaign, the CDC reports that 2 million people suffer infections caused by antibiotic-resistant bacteria and these infections lead to at least 23,000 deaths.⁴

However, antibiotic resistance is only part of the risk of overprescribing antibiotics. Another significant problem is an allergic reaction. Per the ADA, there were 145,000 emergency hospital visits between 2011 and 2015 for adverse events associated with antibiotics and 75 percent involved allergic reactions.⁵ Allergic reactions range from minor skin irritation and digestive tract issues to more severe symptoms, like wheezing, trouble breathing and anaphylaxis.

Another serious concern associated with antibiotics is the increasing cases of Clostridium difficile (C. diff), a serious and sometimes fatal condition. When antibiotics eliminate the protective bacteria that live in the gastrointestinal tract, the C. diff bacteria multiply, causing severe diarrhea. According to Sciencedaily.com, the Minnesota Department of Health (MDH) reported that 15 percent of the cases they kept track of over six years were from antibiotics prescribed by the patients’ dentists.⁶ The lead author of the study, Dr. Stacy Holzbauer, says that reducing outpatient antibiotic prescriptions would lower C. diff rates that don’t occur at hospitals by 17 percent.⁷

Antibiotic overprescribing is an issue that’s personal for Dr. Cook. His mother died of a perforated bowel resulting from a C. diff infection following antibiotic therapy. She died within 24 hours. “She got an antibiotic every time she turned around,” he says of his mother’s case.

Dr. Cook believes that antibiotic resistance is a crucial issue for prescribers today. His patients often come in and demand antibiotics for a toothache. That’s when he educates his patients about antibiotic use. “It’s the whole premise of if you have a splinter in your arm, are you going to take an antibiotic to make it feel better or take the splinter out?” he says.

The opioid crisis has been increasing in the U.S. at an alarming rate. Opioids interfere with pain signals in a patient’s brain and provide pain relief. There are several different types, from natural opioids like morphine and codeine to semi-synthetic opioids such as hydrocodone (Vicodin) and oxycodone (Percoset) and even fully synthetic opioids like fentanyl and methadone.

Last October, U.S. President Donald Trump declared the opioid epidemic a public health emergency and urged the country to be the generation that ends the overdose crisis. Per the American Society of Addiction Medicine (ASAM), 2 million people in the U.S. were addicted to prescription pain relievers in 2015. Those numbers are expected to rise since 2015.⁸ The National Institute on Drug Abuse reports that as many as 115 people in the U.S. die of overdosing on opioids every day.⁹

Up next: What dentists can do to protect patients

What can dentists do to protect patients?

Maintaining the highest standards of patient care while managing patient expectations can be challenging for any doctor. With so much on the line for the patient, however, it’s crucial that dentists do just that when prescribing medication.

For antibiotics:

When it comes to overprescribing, Dr. Sanders believes that staying up to date on the guidelines is vital as they change every few years, particularly with antibiotic prophylaxis.

“Sometimes the dentist or the orthopedic surgeon isn’t up to date on the latest guidelines. As a result, patients get a prophylaxis per the guidelines of five years ago,” Dr. Sanders explains.

In 2012, the ADA changed its stance on premedication for antibiotic prophylaxis for patients with prosthetic joints and orthopedic implants and continued to discourage the practice in 2015.¹⁰ Research showed that dental procedures were not causing prosthetic joint implant infections and that the prophylactic antibiotics were not preventing those infections. The latest guidelines have relatively few cases where antibiotic prophylaxis is indicated.¹¹

However, as a guideline, it means that while most people don’t need a prescription, there are cases where a patient might need one. Dr. Sanders says you have to consider that, too. However, in most cases, a prescription isn’t necessary.

The CDC is working to reduce unnecessary antibiotic use by 50 percent by the year 2020.

The CDC encourages prescribers to follow the framework presented in its Outpatient Antibiotics Stewardship Program.¹² The program seeks to measure antibiotic prescribing, to improve prescribing practices to only necessary cases, to minimize underuse of antibiotics, and to ensure the proper drugs and durations are used. It also enhances any existing guidelines for antibiotic prescribing and ties the standards to evidence-based recommendations about diagnosis and management. There are four core elements to the CDCs proposed Outpatient Antibiotic Stewardship program, including:

1. Commitment: Prescribers should dedicate themselves to the program.
2. Action for policy and practice: They should implement, assess and modify their prescribing behavior as needed.
3. Tracking and reporting: They should monitor and evaluate their prescribing practices.
4. Education and expertise: Education should be an essential element of their prescribing behavior, both for other providers and patients.

Up next: The opioid crisis

For opioids:

The dental industry and professional associations have responded to the opioid crisis. In April 2018, the Journal of the American Dental Association (JADA) published additional evidence that supports that nonsteroidal medications are best for short-term pain management.¹³ The latest findings further support many previous articles supporting the use of over-the-counter pain medication for short-term pain management for patients.

However, for many doctors, the decision not to prescribe opioids happened years ago. Dr. Cook abandoned opioids back in the early 2000s.

“I made a decision a long time ago that opioids shouldn’t be my first choice in pain management for endodontic therapy,” he says. “If I look at my opioid prescription writing for the past 15 years, I have written less than 10 prescriptions a year for post endodontic therapy pain management. When I look at the cases where I did write a prescription, it was for no more than 10-12 tablets.”

The ADA also published a new policy on prescription limits and continuing education for dentists regarding opioids earlier this year. The policy supports mandatory continuing education regarding opioid and other controlled substance prescriptions. Also, the ADA recommends statutory limits for opioid dosage and a prescription that lasts no more than seven days. These recommendations are consistent with the CDC’s evidence-based guidelines.

Finally, the policy encourages prescribers to register and use Prescription Drug Monitoring Programs (PDMPs). A PDMP gathers and analyzes data submitted by pharmacies and prescribers. PDMPs alert practitioners when a patient has been flagged for inappropriate use of opioids; likewise, it alerts officials if practitioners are prescribing opioids inappropriately.

PDMPs helped Dr. Cook avoid a situation with one of his patients last month. A 19-year-old man asked him for an opioid prescription for his pain. Dr. Cook ran a CASPER report that showed the patient had been flagged 10 times in the last year. Dr. Cook took the information back to his patient.

“I said, ‘Listen, you are not getting any narcotics. It’s not going to happen. You can take ibuprofen if you are having some pain and that’s all,’” Dr. Cook recalls.

“As soon as we show them that report, they immediately go, ‘Boy, whatever you did, I feel so much better.’ Then, they are trying to get out of the office as soon as they possibly can,” Dr. Cook says.

When Dr. Sanders, who maintains a private practice in rural Frenchtown, Montana, explains to her patients that over-the-counter medication is as good or better than prescription medication for pain management, her patients often tell her they don’t like taking pills anyway. However, Dr. Sanders recognizes that other dentists don’t receives the same attitude from their patients.

“It’s tough, especially in some areas and cultures, because some people just want a prescription,” Dr. Sanders says. “It’s about patient education and letting them know that giving them the prescriptions maybe isn’t the best thing for them.”

References:

1. “Antibiotic Use in the United States, 2017: Progress and Opportunities.” www.cdc.gov. Web. 17 August 2018. < https://www.cdc.gov/antibiotic-use/stewardship-report/outpatient.html>.

2. “US Prescribing Rate Maps.” www.cdc.gov. Web. 17 August 2018. < https://www.cdc.gov/drugoverdose/maps/rxrate-maps.html>

3. “Antibiotic Resistance Questions and Answers.” www.cdc.gov. Web. 16 August 2018. < https://www.cdc.gov/antibiotic-use/community/about/antibiotic-resistance-faqs.html>.

4. “Be Antibiotics Aware: Smart Use, Best Care.” www.cdc.gov. Web. 16 August 2018. < https://www.cdc.gov/features/antibioticuse/index.html>.

5. Geller AI, Lovegrove MC, Shehab N, et al. National Estimates of Emergency Department Visits for Antibiotic Adverse Events Among Adults-United States, 2011-2015. J Gen Intern Med 2018. From: “Antibiotic Stewardship” www.ada.org. Web. 16 August 2018. < https://www.ada.org/en/member-center/oral-health-topics/antibiotic-stewardship>.

6. “Antibiotics for dental procedures linked to superbug infection.” www.sciencedaily.com. 6 October 2017. Web. 16 August 2018. < https://www.sciencedaily.com/releases/2017/10/171006164847.htm>.

7. ibid

8. “Opioid Addiction: 2016 Facts & Figures.” www.asam.org. Web. 16 August 2018. < https://www.asam.org/docs/default-source/advocacy/opioid-addiction-disease-facts-figures.pdf>.

9. “Opioid Overdose Crisis.” www.drugabuse.com 16 August 2018.

10. “Antibiotic Prophylaxis: Prosthetic Joints and Orthopedic Implants.” www.mouthhealthy.org. Web. 17 August 2018. < https://www.mouthhealthy.org/en/az-topics/a/joint-replacement>.

11. “Antibiotic Prophylaxis Prior to Dental Procedures.” www.ada.org. Web. 21 August 2018. < https://www.ada.org/en/member-center/oral-health-topics/antibiotic-prophylaxis>.

12. “The Core Elements of Outpatient Antibiotic Stewardship.” www.cdc.gov. Web. 21 August 2018. < https://www.cdc.gov/antibiotic-use/community/pdfs/16_268900-A_CoreElementsOutpatient_508.pdf>.

13. Benefits and harms associated with analgesic medications used in the management of acute dental pain. Moore, Paul A. et al. The Journal of the American Dental Association, Volume 149, Issue 4, 256 - 265.e3.