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What’s New in the Patient Safety World
July 2019
Dental Prescribing Called Into Question
We’ve done a few columns on dental patient safety. While most have focused on the risks associated with sedation in dental settings, our March 15, 2016 Patient Safety Tip of the Week “Dental Patient Safety” covered what we thought was the gamut of patient safety issues in dental patients. But one issue has flown under the radar: prescribing patterns.
Some new studies have pointed out overprescribing of opioids and prophylactic antibiotics by dentists.
Hudgins et al. (Hudgins 2019) analyzed visits to ED’s and outpatient clinics for adolescents (13–17 years old) and young adults (18–22 years old). Rates of opioid prescribing were calculated. The authors noted that teens and young adults are at particular high risk for opioid misuse, and opioid prescription in this age group has been linked to future long-term opioid use. Among ED visits, opioid-prescribing rates were highest among adolescents and young adults with dental disorders (59.7% and 57.9%, respectively), followed by adolescents with clavicle (47.0%) and ankle fractures (38.1%).
But who is prescribing these opioids for the dental conditions? It’s quite likely that the emergency physicians are evaluating the patients for the dental problem, prescribing the analgesics, and referring the patients to a dentist or dental clinic.
However, a second study (Suda 2019a) compared opioid prescribing by dentists in the United States and England. The researchers note that dentists are one of the most frequent US prescribers of opioids despite data suggesting that nonopioid analgesics are similarly effective for oral pain. They found that, in 2016, the proportion of prescriptions written by US dentists that were for opioids was 37 times greater than the proportion written by English dentists. In all, 22.3% of US dental prescriptions were opioids compared with 0.6% of English dental prescriptions.
The rate of opioid prescriptions per 1000 population was 35.4 per 1000 for the US population vs 0.5 per 1000 in the England population (a rate 70 times higher in the US) and the number of opioid prescriptions per dentist in the US was 58.2 prescriptions per dentist vs 1.2 prescriptions per dentist in England.
Moreover, opioids with a high potential for abuse, such as oxycodone, were frequently prescribed by US dentists but not prescribed in England.
The same group also looked at dental prescribing of antibiotics (Suda 2019b). They found that 81% of antibiotics prescribed by dentists to prevent infections prior to dental visits are probably unnecessary. Factors associated with unnecessary antibiotic prophylaxis included prosthetic joint devices, tooth implant procedures), female sex, and visits occurring in the western United States. The authors point out something we were unaware of: dentists prescribe about 10% of all antibiotics in the US and, in fact, are the top specialty other than primary care for prescribing antibiotics (Hicks 2015).
In our March 15, 2016 Patient Safety Tip of the Week “Dental Patient Safety” one of the items we noted in the literature was failure to prescribe prophylactic antibiotics before dental procedures in “at risk” patients. But we pointed out that guidelines and recommendations for prophylactic antibiotics had changed considerably and that the evidence was not strong for their use in patients with conditions like total joint prosthetics.
Failure to use antibiotic prophylaxis in patients with artificial heart valves or other foreign bodies that might become infected has been listed as a safety concern. However, most recent guidelines have actually done away with prophylaxis in many cases. Compared with previous recommendations, there are currently relatively few patient subpopulations for whom antibiotic prophylaxis may be indicated prior to certain dental procedures (ADA 2016). For example, for those with hip arthroplasties the current guidelines do not recommend antibiotic prophylaxis prior to dental surgery unless there have been complications related to the hip surgery.
But, before you go blaming dentists, keep in mind that the above studies utilized administrative data and those do not tell us who really recommended the antibiotic prophylaxis. Our own dentist tells us that local orthopedic surgeons from one group always recommend their total joint arthroplasty patients get prophylactic antibiotics before dental work, whereas the other group does not recommend them. And even the orthopedic specialty societies add to the confusion.
The Suda study looked at dental procedures performed between 2011 and 2015, a time period in which recommendations and guidelines for use of prophylactic antibiotics in patients with joint replacements were in a state of flux. In 2012, a joint effort by the American Academy of Orthopedic Surgeons and the American Dental Association did a thorough review of the issue of antibiotic prophylaxis in patients with joint implants in 2012 (AAOS/ADA 2012) and came up with the following recommendation: “The practitioner might consider discontinuing the practice of routinely prescribing prophylactic antibiotics for patients with hip and knee prosthetic joint implants undergoing dental procedures.” The word “might” sounds pretty squishy to us, and obviously was not strong enough to dissuade some orthopedic surgeons from recommending antibiotic prophylaxis for their total joint replacement patients undergoing dental procedures.
The most recent ADA recommendation for patients with prosthetic joint implants (ADA 2019) cites the January 2015 ADA clinical practice guideline (Sollecito 2015), based on a 2014 systematic review and states, “In general, for patients with prosthetic joint implants, prophylactic antibiotics are not recommended prior to dental procedures to prevent prosthetic joint infection.” It does note that for patients with a history of complications associated with their joint replacement surgery who are undergoing dental procedures that include gingival manipulation or mucosal incision, prophylactic antibiotics should only be considered after consultation with the patient and orthopedic surgeon.
The Suda article (Suda 2019b) points out that, while the rate of antibiotic prescriptions overall has decreased nationally in the past several years, antibiotic prescriptions by dentists have remained steady.
Recommendations now for antibiotic prophylaxis during dental procedures involve primarily patients at highest risk for infective endocarditis (eg. those with prosthetic valves, previous endocarditis, congenital heart disease, transplant patients with valvulopathy). Bottom line: always check to ensure the most up-to-date guidelines for prophylaxis are followed.
Good antibiotic stewardship prevents unnecessary administration of antibiotics that may lead to emergence of microbial resistance to the antibiotics or promote C. difficile infections or other antibiotic-associated adverse events. These risks outweigh the relatively small risk of seeding a prosthetic joint.
Some of our previous columns on dental patient safety issues:
March 15, 2016 “Dental Patient Safety”
August 2016 “Guideline Update for Pediatric Sedation”
March 28, 2017 “More Issues with Dental Sedation/Anesthesia”
August 8, 2017 “Sedation for Pediatric MRI Rising”
November 28, 2017 “More on Dental Sedation/Anesthesia Safety”
References:
Hudgins JD, Porter JJ, Monuteaux MC, Bourgeois FT. Trends in Opioid Prescribing for Adolescents and Young Adults in Ambulatory Care Settings. Pediatrics 2019; 143(6): e20181578
Suda KJ, Durkin MJ, Calip GS, et al. Comparison of Opioid Prescribing by Dentists in the United States and England. JAMA Netw Open 2019; 2(5): e194303 May 24, 2019
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2734067
Suda KJ, Calip GS, Zhou J, et al. Assessment of the Appropriateness of Antibiotic Prescriptions for Infection Prophylaxis Before Dental Procedures, 2011 to 2015. JAMA Netw Open 2019; 2(5): e193909 May 31, 2019
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2734798
Hicks LA, Bartoces MG, Roberts RM, et al. US outpatient antibiotic prescribing variation according to geography, patient population, and provider specialty in 2011. Clin Infect Dis 2015; 60(9): 1308-1316
https://academic.oup.com/cid/article/60/9/1308/405905
ADA (American Dental Association). Antibiotic Prophylaxis Prior to Dental Procedures. February 18, 2016
http://www.ada.org/en/member-center/oral-health-topics/antibiotic-prophylaxis
AAOS (American Academy of Orthopedic Surgeons) and ADA (American Dental Association). Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures. Evidence-Based Guideline and Evidence Report. December 7, 2012
http://www.aaos.org/Research/guidelines/PUDP/PUDP_guideline.pdf
ADA (American Dental Association). Antibiotic Prophylaxis Prior to Dental Procedures.
Last updated March 19, 2019
https://www.ada.org/en/member-center/oral-health-topics/antibiotic-prophylaxis
Sollecito TP, Abt E, Lockhart PB, et al. The use of prophylactic antibiotics prior to dental procedures in patients with prosthetic joints. The Journal of the American Dental Association 2015; 146(1): 11-16.e8
https://jada.ada.org/article/S0002-8177(14)00019-1/fulltext
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