Part 2. Current prescribing trends of dental non-antibacterial medicines in Australia from 2013 to 2016

Antibiotic prescribing patterns among dentists in Italy and Albania: A comparative questionnaire analysis

Objective

To investigate the therapeutic and prophylactic use of antibiotics in dentistry in two countries.

Methods

This study used questionnaires to examine the prescribing habits of dentists in Italy (9th country in Europe for systemic antibiotic administration) and Albania an Extra European Union Country. A total of 1300 questionnaires were sent to Italian and Albanian dentists.

Results

In total, 180 Italian and 180 Albanian dentists completed the questionnaire. Penicillin use was higher in Italy (96.6 %) than Albania (82.8 %). Only 26.1 % of Italian dentists and 32 % of Albanian dentists followed the national guidelines for antibiotic administration.

Conclusions

Dentists tend to overprescribe antibiotics for treating existing conditions or as prophylaxis. They also highlighted a lack of adherence to established guidelines for antibiotic use. In addition, factors such as age, nationality, and sex appeared to influence the choice of antibiotics.

Clinical significance

Recently, the growth of antibiotic-resistant bacteria has become a global concern. The authors of this article highlight how dentists often prescribe antibiotics without a real need. Limiting the use of antibiotics in this category may help mitigate antibiotic resistance.

High prevalence of potential psychotropic drugs interactions among Brazilian dental patients

OBJECTIVE

To determine the prevalence of potential drug-drug interactions involving psychotropics prescribed by dentists, and dispensed by the public healthcare system, as well as to describe the severity and level of evidence of those interactions in the state of Minas Gerais, Brazil.

MATERIALS AND METHODS

We conducted data analysis from pharmaceutical claims in which dental patients received systemic psychotropics in 2017. Data from the Pharmaceutical Management System provided the drug dispensing history of the patients, allowing the identification of those on concomitant medication use. The outcome was the occurrence of potential drug-drug interactions, which were detected according to IBM Micromedex®. Independent variables were the patient's sex, age, and the number of drugs used. Descriptive statistics was performed using SPSS v. 26.

RESULTS

Overall, 1480 individuals were prescribed psychotropic drugs. The prevalence of potential drug-drug interactions was 24.8% (n = 366). The total of 648 interactions was observed and, most of which were of major severity (n = 438, 67.6%). Most interactions occurred in female individuals (n = 235; 64.2%), with 46.0 (±17.3) years-old, concurrently taking 3.7 (±1.9) drugs.

CONCLUSION

A substantial proportion of dental patients presented potential drug-drug interactions, mostly of major severity, which might be life-threatening.

Dental Pain Medication Prescriptions in Minas Gerais, Brazil (2011-2021): A Time-Series Analysis

To describe trends of dentist-prescribed non-steroidal anti-inflammatory drugs (NSAIDs) and analgesics, from January 2011 to December 2021, as well as to examine the relationship between these trends and characteristics of public oral health services in Minas Gerais, Brazil. In this time-series analysis, all drugs were classified according to the Anatomical Therapeutic Chemical classification system. Drugs categorized as NSAIDs (M01A), and other analgesics and antipyretics (N02B) were included for analysis. The outcome was the number of Defined Daily Doses (DDDs)/1000 inhabitants/year for NSAIDs and analgesics in each town. Covariates referred to characteristics of public oral health services, such as coverage, estimates of dental procedures, and frequency of toothache. Linear time-series regression models were used to determine the influence of covariates on the outcome. Overall, there were 58,482 prescriptions of NSAIDs recorded in thirty-eight towns, while 47,499 prescriptions of analgesics in forty-three towns. For each year, there was a 0.38 (p < 0.001), and 0.28 (p < 0.001) increase in the average log of DDD/1000 inhabitants/year for NSAIDs and analgesics, respectively. A positive association was detected between toothache (p < 0.001) and the prescription of NSAIDs. Over the eleven years, there was a general rising trend in the prescriptions. Toothache was the only characteristic of public oral health services associated with the prescription rates of NSAIDs, implying that as the frequency of toothaches increase, so do the prescriptions of NSAIDs in the studied towns.

Association of sociodemographic factors with the prescription pattern of opioids for dental patients: a systematic review

Aim To evaluate the association of patients' sociodemographic factors (sex, age, ethnicity, income, educational level, living environment and health insurance) with the prescription pattern of opioids provided by oral health practitioners.Methods Observational studies that evaluated the association of patients' sociodemographic factors and the likelihood of receiving an opioid prescription provided by an oral health practitioner were eligible. Electronic searches were conducted in Medline (PubMed), Embase, Scopus, Web of Science, LILACS, SciELO, Google Scholar, and OpenGrey up to March 2021. Two authors independently screened the studies, performed data extraction, and assessed the risk-of-bias using the critical appraisal tools developed by the Joanna Briggs Institute (JBI). Certainty of the evidence was assessed with the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE).Results Eight studies were included in this systematic review. Publication year ranged from 2011 to 2021. Narrative synthesis showed with very low certainty of evidence that younger individuals were more likely to receive a prescription of opioids than older individuals. Regarding the other sociodemographic factors and the prescriptions of opioids in dentistry, the evidence is controversial. Risk of bias was low for most items assessed in the included studies.Conclusion The available evidence suggests that there is an association between patients' sociodemographic factors and the prescription patterns of opioids provided by oral health practitioners.

Prescribing drugs of dependence in dentistry: a review of␣legal and regulatory considerations

The misuse of drugs of dependence is a major public health issue in Australia, and prescribing of these medications by dentists has increased in recent years. While there has been much focus on the appropriate indications and clinical use of these medicines in dental practice, the legal requirements of prescribing are equally important. Dental practitioners need to be aware of their legal obligations, as inappropriate prescription practices may lead to regulatory or criminal prosecution. Although dentists hold registration through the National Scheme␣and there is nationally standardised scheduling of drugs in Australia, the legislation governing drug laws differs for each state and territory, especially when prescribing drugs of dependence. This article summarises the legislation governing the prescription of drugs of dependence in Australia that is relevant to dental practice, providing insights into how dentists might contribute to the appropriate, safe and legal use and management of these medications.

Prescriptions of analgesics and anti-inflammatory drugs in municipalities from a Brazilian Southeast state

The objective of this study was to describe dental prescriptions of non-steroidal anti-inflammatory drugs (NSAID), opioids, and analgesics dispensed by the Brazilian National Health System (BNHS, SUS in Portuguese) of a Southeastern state from January to December 2017, and to analyze their association with socioeconomic and oral health care services' characteristics at municipal level. Data were collected from the Brazilian Integrated Pharmaceutical Care Management System. Medicines were grouped according to the Anatomical Therapeutic Chemical Classification System. The total number of Defined Daily Doses (DDD) and DDD per 1,000 inhabitants (inhab.) per year were presented and compared between groups of municipalities. Data analysis used the Classification and Regression Tree model performed with IBM SPSS 25.0. The total number of NSAID, opioids, and analgesics prescriptions was 70,747 and accounted for 354,221.13 DDD. The most frequently prescribed medicine was ibuprofen (n = 24,676; 34.88%). The number of dental practitioners in the BNHS per 1,000 inhab. (p < 0.001), first dental appointment coverage (p = 0.010), oral health teams per 1,000 inhab. (p=0.022), and the proportion of rural population (p = 0.014) were variables positively associated with the number of DDD of NSAID per 1,000 inhab. per year. Bolsa Família program coverage per 1,000 inhab. (p = 0.022) was negatively associated with NSAID prescription. Regarding analgesics, first dental appointment coverage (p=0.002) and Bolsa Família program coverage per 1,000 inhab. (p = 0.012) were positively associated with DDD per 1,000 inhab. per year. In conclusion, dental prescriptions of analgesics and NSAID in the BNHS were associated with socioeconomic and oral health care services' characteristics.

Financial contributions made by patients towards dispensed medicines prescribed by Australian dentists from 2006 to 2018: a cost-analysis study

Objective This cost-analysis study explored Pharmaceutical Benefits Scheme (PBS) data to determine the financial patient contribution (PC) towards dispensed medications prescribed by dentists and temporal trends in cost contributions. Methods For this study we used the PBS online dataset and only included concessional data in the analysis. Data on dental medications dispensed under the PBS from 2006 to 2018 were accessed. For all medicines aggregated to different pharmacological categories (antibiotics, analgesics and opiates, anti-inflammatories, antifungals, benzodiazepines, anticonvulsants and anti-emetics, and emergency medications), a temporal trend was generated using annual PC data. Cumulative patient and mean annual PC data were also generated in a similar manner. Results Cumulative PC over the study period for dental PBS prescriptions was A$28783361 (A$5.55 per dispensing). The mean annual PC for dental PBS was A$2214105 (for the entire concessional population from 2006 to 2018), with a statistically significant and strong correlation between year and PC (Dental PBS, A$59756 per year; r=0.98: P<0.0001). Antibiotics represented the highest proportion of PC (87.8%), whereas the lowest proportion of PC was for emergency medications (e.g. adrenaline, atropine, glucagon, naloxone), which amounted to 0.003%. Conclusions This study highlights the increasing contributions made by patients towards antibiotic prescriptions. What is known about the topic? Australian dentists can independently prescribe subsidised medications as per a set scope for general and specialist dentists, regulated under the PBS with requisite adherence to specific legal requirements. What does this paper add? This is the first study highlighting the increased level of patient financial contributions towards dental medicines, according to different pharmacological categories, dispensed by pharmacists in Australia. What are the implications for practitioners? This study creates a base for future research assessing the appropriateness of the PBS subsidy and the PBS Safety Net threshold, possibly reassessing the out-of-pocket pricing on brand substitution and appropriately reassessing the current dental PBS schedule.

Dispensing patterns of medicines prescribed by Australian dentists from 2006 to 2018 - a pharmacoepidemiological study

OBJECTIVES

Dentists are independent prescribers that can prescribe subsidised medicines under the Australian Pharmaceutical Benefits Scheme (PBS). It is hypothesised that increased dental prescribing can partly be accounted for by the growth in both the Australian population and the number of practising dentists. This pharmacoepidemiological study aims to determine the dispensing patterns of medications amongst dentists and to identify trends over time.

MATERIALS AND METHODS

Data on dental medications under PBS from 2006 to 2018 were accessed. All the dentist-prescribed concessional medicines dispensed at pharmacies in 2018 were included for time trend analysis. Cumulative dispensing counts and defined daily dose (DDD) per 1,000 concessional population days (DPD) were analysed for time trend analysis.

RESULTS

Out of the 56 medications within the dental PBS schedule, the top 20 medicines had a total cumulative dispensing count of 5,058,556, which accounts for 97.4% of the total dispensing count. Eleven out of 20 medicines were antibiotics. Overall, increases were observed for seven out of 20 medicines (amoxicillin + clavulanic acid, clindamycin, ibuprofen, diazepam, oxycodone, tramadol, naproxen) in both dispensing count and trend, as expressed per DPD.

CONCLUSION

This study highlights the increasing dispensing pattern and trends of dentist-prescribed antibiotics, opioids and benzodiazepines. Further investigation may be required to determine whether the medicine use is appropriate. In the future, this could provide new educational opportunities on the appropriate use of medicines for dentists.

Improvement of dental prescribing practices using education and a prescribing tool: A pilot intervention study

AIMS

Antibiotic resistance is a global public health problem. Around 55% of dental antibiotic prescribing is deemed inappropriate. The aim of this multimodal interventional pilot study was to assess the effect on prescribing of education and a dentally designed prescribing website.

METHODS

Twenty-six dentists were recruited for the 12-week study using a pre-post design. Dentists self-recorded their prescribing of antibiotics, analgesics and anxiolytics for 6 weeks. After dentists were provided education and website access, they recorded their prescribing for a further 6 weeks. Four outcomes were measured comparing the prescribing before and after the intervention: (i) the number of inappropriate indications for which antibiotics were prescribed; (ii) the number of prescriptions; (iii) accuracy of the prescriptions according to the Australian therapeutic guidelines; and (iv) the confidence of practitioners towards the prescribing website. Participants were interviewed for feedback.

RESULTS

There was a substantial reduction of 44.6% in the number of inappropriate indications for which antibiotics were prescribed after the intervention and a decrease of 40.5% in the total number of antibiotics. Paracetamol with codeine substantially reduced by 56.8%. For the 3 most commonly prescribed antibiotics (amoxicillin, phenoxymethylpenicillin and metronidazole), there was the improvement in the accuracy of the prescriptions ranging from 0-64.7 to 74.2-100%.

CONCLUSION

This pilot study showed the intervention of targeted education and the prescribing tool was effective in improving dental prescribing, knowledge and confidence of practitioners, as well as providing an effective antibiotic stewardship tool. This context-specific intervention shows substantial promise for implementation into dental practice.

Dental opioid prescribing rates after the up-scheduling of codeine in Australia

The misuse of pharmaceutical opioids is a major public health issue. In Australia, codeine was re-scheduled on 1 February 2018 to restrict access; it is now only available on prescription. The aim of this study was to measure the change in dental opioid prescriptions, one year before and after the codeine re-scheduling in Australia and to assess dental prescribing rates of opioids for 2018 by population and by clinician. Data was extracted for dental opioids for the year immediately prior and after the codeine up-schedule (1 February 2017-31 January 2019) from the publicly-available national prescription database (Pharmaceutical Benefits Scheme). Descriptive statistics, T-tests and odds ratios were used to identify significant prescribing differences. Codeine, codeine/paracetamol, oxycodone and tramadol use increased significantly the year after the codeine restriction than the previous year (13.8–101.1%). Australian dentists prescribed 8.6 prescriptions/1,000 population in 2018, with codeine/paracetamol accounting for most prescriptions (96%). The significant increase in opioid prescribing highlights that Australian dentists may be contributing to the misuse of pharmaceutical opioids. Educational efforts should be targeted at the appropriate use of opioids and patient selection. Dentists should be added to the prescription monitoring system SafeScript so they can make informed decisions for patients who are potentially misusing opioids.

A survey of prescribing practices by general dentists in Australia

BACKGROUND

Numerous studies of dental antibiotic prescribing show that overprescribing is a worldwide occurrence. The aim of this study was to assess prescribing practices of general dentists in Australia for antibiotics, analgesics and anxiolytics and to determine the extent to which prescribing is in accordance with current guidelines.

METHODS

A structured questionnaire was sent to 1468 dentists in Victoria and Queensland in July-August 2018. The questionnaire covered demographics, clinical conditions where dentists prescribe antibiotics, non-clinical factors which influence prescribing, and medicines for anxiolysis and pain relief. Responses were scored using a system based on the current Australian therapeutic guidelines. Logistic regression was used to determine the relative importance of independent variables on inappropriate prescribing.

RESULTS

Three hundred eighty-two responses were received. Overall, 55% of overprescribing of antibiotics was detected, with a range of 13-88% on a routine or occasional basis depending on the scenario. Between 16 and 27% of respondents inappropriately preferenced analgesics over anti-inflammatories for dental pain; 46% of those who prescribed anxiolytic medicines did so inappropriately, with varying regimens and choices outside the guidelines. Years of practice was the main demographic factor influencing prescribing, with recent graduates (0-5 years) generally scoring better than their colleagues for antibiotic prescribing (p < 0.05).

CONCLUSIONS

Future interventions could be directed towards the appropriate role and use of antibiotics, shortfalls in knowledge and appropriate choices of medicines for pain relief and anxiolysis. Given that the most overprescribing occurred for localised swellings (88%), this area could be focused on in continuing education as well as ensuring it is addressed in undergraduate teaching. Continuing education on the appropriate use of medicines can be targeted at more experienced dentists as well as patients, especially those who expect antibiotics instead of treatment.

TRIAL REGISTRATION

University of Melbourne Human Ethics Sub-Committee; ID: 1750768.1 .

Perceptions, attitudes and factors that influence prescribing by general dentists in Australia: A qualitative study

BACKGROUND

Longitudinal studies of dental prescribing in Australia show that dentists make some inappropriate prescribing choices; literature has shown that dentists tend to overprescribe antibiotics and prescribe for incorrect indications. The unnecessary use of antibiotics is a contributing factor towards the development of antibiotic resistance. The aims of the study were to obtain a greater understanding of the perceptions, attitudes and factors that influence dental prescribing for all major relevant drug classes.

METHOD

Semi-structured interviews of 15 purposively sampled dentists practising in Victoria, Australia were conducted from June-September 2018. Two dentists practised in rural areas and the remainder in urban locations. The range of clinical experience varied from 2.5 to 37 years, with a mean of 13 years. The transcripts were analysed thematically.

RESULTS

Dentists generally preferred amoxicillin as first-line therapy for odontogenic infections, with some confusion about the spectrum and uses of antibiotics. Overprescribing was evident, mostly due to basing judgement for use of antibiotics on symptoms rather than clinical signs. Other factors, such as time pressure, patient expectations, pressure from assistant staff, concern about online criticism and medico-legal considerations, influenced prescribing. Of the dentists who prescribed anxiolytics, most did not have a care protocol for their sedated patients.

CONCLUSION

A variety of prescribing practices were described, and future interventions should target misconceptions around the appropriate use and choice of antibiotics, resources to address the shortfall in knowledge of therapeutics, patient education and staff training, as well as appropriate care and monitoring of sedated patients.