Preventing medication errors in dental practice: An australian perspective.

INTRODUCTION: Prescribing errors are a common type of medication error, even in dental practice. However, prescribing is a skill to which little attention is paid, as the profession is mostly focussed on performing dental procedures, eschewing the use of drugs, to treat dental conditions. Most dentists in Australia report learning little about prescribing during their university training, gaining these skills informally on the job after they graduate. Despite this, dentists are the second largest prescriber group in Australia and prescribe a wide variety of drugs including antibiotics, non-steroidal anti-inflammatory drugs, opioid analgesics, muscle relaxants and anxiolytics. OBJECTIVES: To summarise medication safety, medication and prescribing errors in the context of dental practice. DATA: The sources of medication and prescribing errors are reviewed. SOURCES: For this narrative review, pivotal concepts regarding sources of medication error and types of prescribing error are highlighted. The Swiss Cheese model of prescribing errors is also discussed, highlighting possible interventions when errors can be detected and averted. STUDY SELECTION: Case reports of prescribing error in dentistry in Australia are presented, highlighting examples of how dental prescribing is prone to error. CONCLUSIONS: Solutions lie in addressing the systems and processes in which dentists work. Examples include implementing forced functions such as checklists and electronic prescribing tools. CLINICAL SIGNIFICANCE: Dentists are the second largest prescriber group in Australia and prescribe a wide variety of drugs. As such, prescribing errors are common in dental practice. Solutions to reduce medication and prescribing errors lie in addressing the systems which govern dentistry, as well as implementing forced functions such as prescribing tools.

Outcomes to evaluate care for adults with acute dental pain and infection: a systematic narrative review.

OBJECTIVE: To identify outcomes reported in peer-reviewed literature for evaluating the care of adults with acute dental pain or infection.DesignSystematic narrative review. SETTING/PARTICIPANTS: Primary research studies published in peer-reviewed literature and reporting care for adults with acute dental pain or infection across healthcare settings. Reports not in English language were excluded. STUDY SELECTION: Seven databases (CINAHL Plus, Dentistry and Oral Sciences Source, EMBASE, MEDLINE, PsycINFO, Scopus, Web of Science) were searched from inception to December 2020. Risk of bias assessment used the Critical Appraisal Skills Programme checklist for randomised controlled trials and Quality Assessment Tool for Studies of Diverse Design for other study types. OUTCOMES: Narrative synthesis included all outcomes of care for adults with acute dental pain or infection. Excluded were outcomes about pain management to facilitate treatment, prophylaxis of postsurgical pain/infection or traumatic injuries. RESULTS: Searches identified 19 438 records, and 27 studies (dating from 1993 to 2020) were selected for inclusion. Across dental, pharmacy, hospital emergency and rural clinic settings, the studies were undertaken in high-income (n=20) and low/middle-income (n=7) countries. Two clinical outcome categories were identified: signs and symptoms of pain/infection and complications following treatment (including adverse drug reactions and reattendance for the same problem). Patient-reported outcomes included satisfaction with the care. Data collection methods included patient diaries, interviews and in-person reviews. DISCUSSION: A heterogeneous range of study types and qualities were included: one study, published in 1947, was excluded only due to lacking outcome details. Studies from dentistry reported just clinical outcomes; across wider healthcare more outcomes were included. CONCLUSIONS: A combination of clinical and patient-reported outcomes are recommended to evaluate care for adults with acute dental pain or infection. Further research is recommended to develop core outcomes aligned with the international consensus on oral health outcomes. PROSPERO REGISTRATION NUMBER: CRD42020210183.

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.

Trends in Dental Medication Prescribing in Australia during the COVID-19 Pandemic.

INTRODUCTION: The coronavirus disease 2019 (COVID-19) pandemic and subsequent restrictions on dental services have had a significant impact on the provision of dental care in Australia and around the world. OBJECTIVES: To investigate the impact of COVID-19 on medications prescribed by dentists under the Australian Pharmaceutical Benefits Scheme (PBS). METHODS: Data on the number of dental prescriptions dispensed for all medications listed on the PBS Dental Schedule, from January 2019 to June 2020, were extracted from publicly available data sets. Analysis of prescription trends was performed for 1) total medications, 2) each major medication class, and 3) individual medications. The number of prescriptions dispensed in each month from January 2020 to June 2020 was compared to the same month in 2019 to determine the relative (percentage) change, and z statistics were used to determine whether changes were statistically significant. RESULTS: There was a significant decrease in dental prescriptions in April 2020 compared to April 2019 (14,785, 18%; P < 0.05). Decreases in prescriptions for antibiotics (10,512, 16%; P < 0.05) and opioid analgesics (3,129, 18%; P < 0.05) were smaller compared to other major medication classes. There was a significant increase in June 2020, compared with June 2019, for prescriptions of amoxicillin with clavulanic acid (4,903, 20%; P < 0.05), tramadol (89, 46%; P < 0.05), and oxycodone (381, 73%; P < 0.05). CONCLUSION: Dental service restrictions during COVID-19 likely drove an unmet need for routine dental treatment, which had significant implications for public oral health following easing of restrictions. During the initial surge and subsequent lockdown, antibiotics and opioid analgesics may have been used an as alternative to routine operative treatment. Continued professional guidance is required to ensure dental prescribing remains evidence based during the pandemic period. KNOWLEDGE TRANSFER STATEMENT: The COVID-19 pandemic and subsequent restrictions on dental practice have had a profound impact on the provision of dental care in Australia and elsewhere in the world. In this context, population-level medication surveillance is important to identify and respond to changes in prescribing patterns that have arisen due to COVID-19 and restrictions on the provision of dental care. This research is particularly important for governments, regulators, and professional associations to ensure therapeutic guidelines and recommendations during the pandemic period remain relevant and evidence based.

Each for Equal: Gender Inequity in Dentistry in Australia.

OBJECTIVE: While there is an increasing number of women entering the dental profession, they are still underrepresented in leadership roles in major dental organizations, academia, and journal boards. Keynote and invited speaking roles in professional and scientific conferences recognize expertise and leadership and are key factors in career advancement and academic promotions. The aim of this study was to investigate gender differences in representation at dental continuing professional development (CPD) events and conferences in Australia. METHODS: An analysis of the gender of speakers was conducted with CPD and conference programs that are publicly available online from the federal and Victorian branches of the Australian Dental Association, the peak national body for dentists. RESULTS: The planned 2020 Victorian Branch CPD program featured 30 events, with a mean 2.5 speakers per event. There were 58 scientific presentations in the schedule, 22 (38%) of which were allocated to female speakers. Seven CPD events in 2020 included only female speakers, and 13 included only male speakers.The 37th and 38th Australian Dental Congresses featured 25% and 36% of female speakers, respectively. All keynote speakers were male for both events, and men accounted for 86% and 93% of international speakers. CONCLUSIONS: While women are approaching parity in local and state-level CPD events, there is a large discrepancy in the male-to-female speaker ratio for major national conferences. Suggestions to improve gender imbalance include having women on the convening committee and developing and implementing policies to address the imbalance. There has been significant progress in addressing gender inequity in dentistry, but gender-balanced leadership in major conferences still needs to be addressed. KNOWLEDGE TRANSFER STATEMENT: The findings of this study show that while women may be approaching parity with small continuing professional development events, they are still underrepresented as speakers in major conferences. It is recommended that active policies be implemented to reduce the imbalance to ensure gender-balanced leadership in one aspect of the dental profession in Australia.

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 review of drugs that contribute to bleeding risk in general dental practice.

The risk of postoperative bleeding is a daily concern for many general dental practitioners. A thorough medical and medication history must be taken to consider all risk factors, particularly drugs, that contribute to bleeding risk. While the risk from drugs such as aspirin, warfarin and clopidogrel are well known, the extent to which new antiplatelet agents and direct oral anticoagulants affect bleeding risk is less well understood. In addition, there are drugs other than antithrombotics, such as antidepressants and complementary medicines that also impair haemostasis. The aim of this paper is to provide dentists with an updated overview of the drugs commonly encountered in general dental practice that can contribute to a patient's postoperative bleeding risk.

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 .

Oral manifestations of illicit drug use.

The use of illicit and misuse of licit drugs is a global public health problem, with illicit drug use being responsible for 1.8% of the total disease burden in Australia in 2011. Oral adverse effects associated with illicit drug use are well-established, with aggressive caries, periodontitis, bruxism, poor oral hygiene and general neglect documented. Other factors such as a high cariogenic diet and lifestyle, social and psychological factors compound the poorer oral health in illicit drug users. Literature has shown that the oral health-related quality of life among injecting drug users is poorer compared with the Australian general population and the overall quality of life of addicted people correlates with caries experience. Thus, the role of the dentist is imperative in managing the oral health of these individuals. Given their widespread recreational use, it is likely that dental practitioners will encounter patients who are regular or past users of illicit drugs. The aim of this article is to describe the prevalence and mechanism of action of commonly used illicit drugs in Australia, including cannabis, methamphetamine, cocaine and heroin and to inform dentists about the common orofacial presentations of their side effects to help with patient management.

Antibiotic resistance and relevance to general dental practice in Australia.

Antibiotic resistance is a well-established global public health crisis, with the use and misuse of antibiotics being the principal cause of bacterial resistance. Studies in both Australia and overseas have demonstrated that the dental prescribing of antibiotics is increasing and that dentists tend to prescribe antibiotics unnecessarily and for incorrect clinical indications. Dental practitioners in Australia also prefer to prescribe moderate to broad-spectrum antibacterial agents and make some inappropriate antibiotic prescribing choices. This review aims to inform dentists about the overall scope and development of bacterial resistance, approaches and challenges to reducing resistance and, ultimately, the role of dental prescribers in practising with optimal antibiotic stewardship.

Part 1. Current prescribing trends of antibiotics by dentists in Australia from 2013 to 2016.

BACKGROUND: Literature has shown dentists tend to overprescribe antibiotics and do not always prescribe in accordance with recommended guidelines. Unnecessary prescribing is one major factor that contributes to the development of antibiotic resistance. The aim of the present study was to assess the antibacterial prescribing patterns of dentists in Australia from 2013 to 2016. METHODS: Data on dental antibacterial prescriptions dispensed under the Pharmaceutical Benefits Scheme (PBS) from 2013 to 2016 was accessed and prescribing trends analysed. The prescribing rates were standardized to the dose and population. RESULTS: There was a slight decrease in the dispensed use of most antibacterials from 2013 to 2016, but there was a significant increase in the dispensed use of amoxicillin/clavulanic acid of 11.2%. Amoxicillin was the most commonly dispensed antibiotic, accounting for approximately 65% of all antibacterials from 2013 to 2016, while phenoxymethylpenicillin accounted for only 1.4% of prescriptions in 2016. There were low but significant quantities of dispensed antibiotic prescriptions that do not fit with current guidelines. CONCLUSIONS: The data suggest that dentists in Australia are prescribing some antibiotics inappropriately and there is a preference for moderate- to broad-spectrum agents. The current PBS dental schedule is inconsistent with prescribing guidelines and may contribute to inappropriate prescribing.

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

BACKGROUND: There is limited literature regarding dental prescribing preferences for medicines other than antibiotics. This study aimed to describe the prescribing trends of dispensed prescription medicines by dentists in Australia from 2013 and 2016 and assess adherence to current guidelines. METHODS: Data were accessed from the Department of Health of all dental prescriptions dispensed under the Pharmaceutical Benefits Scheme (PBS) from 2013 to 2016 and prescribing patterns were analysed. The prescribing rates were standardized to the dose and population. RESULTS: There was an overall increase in the standardized use of opioid analgesics by almost 30% over the time frame, with the combination paracetamol 500 mg plus codeine 30 mg tablet accounting for the majority of dispensed opioid prescriptions (96.2% in 2016). Dispensed benzodiazepine prescriptions increased by 14.6%. CONCLUSIONS: The increase in the consumption of opioids is concerning, suggesting that continuing education is required for dentists to better understand their limited role in managing dental pain and potential for abuse. The substantial increase in the dispensed use of benzodiazepines also requires further investigation and there were some drugs prescribed inappropriately and not in accordance with guidelines. Consideration could also be given to reviewing the drugs listed on the PBS for dental prescribing.

Restoration of shoulder abduction in brachial plexus avulsion injuries with double neurotization from the spinal accessory nerve: a report of 13 cases.

In upper (C5-C7) and total (C5-T1) root avulsion brachial plexus injury, a method of double neurotization from a single donor spinal accessory nerve to two target nerves (suprascapular nerve and axillary nerve) may be done, leaving donor nerves available for reconstruction procedures to restore other aspects of upper limb function. A mean range of shoulder abduction of 91° (SD 25°) was achieved through this procedure in our study of 13 cases, of which seven cases were C5-C7 root avulsion and six cases were C5-T1 root avulsion brachial plexus injuries. Six of the former group and three of the latter group achieved >90° shoulder abduction. The technique of double neurotization from a single donor nerve provides favourable results in restoring shoulder abduction in avulsion brachial plexus injuries. LEVEL OF EVIDENCE: IV.

Combined volar and dorsal plating for complex comminuted distal radial fractures.

PURPOSE: To review outcomes of combined volar and dorsal locked plating for AO type-C3 complex comminuted distal radial fractures. METHODS: Records of 24 patients aged 17 to 77 (mean, 53.3) years who underwent combined volar and dorsal locked plating for AO type-C3 distal radial fractures with volar and dorsal metaphyseal and intra-articular comminution were reviewed. 21 were closed fractures, and 3 were Gustilo-Anderson type-1 open fractures. Bone union, volar tilt, radial inclination, radial height, range of motion, grip strength, and any complications were assessed by a single hand surgeon. RESULTS: After a mean follow-up of 17 (range, 14-25) months, the mean palmar flexion was 49º (range, 30º-80º), dorsiflexion was 52º (range, 30º-80º), supination was 86º (range, 60º-90º), pronation was 77º (range, 30º-90º), radial deviation was 16º (range, 5º-30º), and ulnar deviation was 27º (range, 10º-50º). The mean grip strength of the injured hand was 69.2% of the uninjured side. The mean time to radiological union was 3.9 (range, 2.5-6.0) months; no patient had non-union. At the time of union, the mean volar tilt was 5º (-22º-14º), radial inclination was 18.6º (8º-28º), and radial height was 8.5 mm (5.0 mm-13.6 mm). One patient had collapse of the dorsal fragment resulting in a dorsal tilt of 22º and limited (30º) forearm pronation. The severity of dorsal metaphyseal comminution had not been recognised and bone grafting was not performed. The patient also had minor complications of little finger flexor tendon irritation and carpal tunnel syndrome. She underwent implant removal and carpal tunnel release at 8 months. One patient had implant-related extensor digitorum communis irritation. Another patient had non-specific chronic wrist pain, which was resolved at one year. No patient had infection, tendon rupture, or complex regional pain syndrome. Four patients underwent implant removal, including 2 who had no implant-related problems. CONCLUSION: Combined volar and dorsal plating enables early mobilisation and good outcome for certain complex comminuted distal radial fractures.

Arthroscopic debridement of intercarpal ligament and triangular fibrocartilage complex tears.

INTRODUCTION: Wrist arthroscopy has evolved since its inception to become an essential diagnostic and therapeutic tool for the management of various wrist disorders. Our study aimed to examine the outcomes of arthroscopic debridement in the treatment of scapholunate (SL), lunotriquetral (LT) and triangular fibrocartilage complex (TFCC) tears. METHODS: We conducted a retrospective review of 68 consecutive wrist arthroscopies performed at our institution between January 2000 and July 2005. All the patients complained of wrist pain, which often interfered with their daily activities, work or sports. A standard arthroscopic technique was employed in all. Any intercarpal ligament or TFCC tears found were debrided. RESULTS: There were 42 patients with TFCC tears, 58 with SL tears and 49 with LT tears. At a mean follow-up time of 16.6 months, 85.3% of the patients reported an improvement in symptoms and 27.9% had improved range of motion. Grip strength improved by 11.8%. All except two patients returned to their original activities. Outcome following arthroscopic debridement was determined using the Mayo Modified Wrist Score. Based on the postoperative wrist scores of 47 patients, 24 were rated excellent, 17 good, four fair and two poor. By comparing the pre- and postoperative wrist scores of 31 patients, we were able to demonstrate significant improvement in patients who underwent wrist arthroscopies. CONCLUSION: Our study demonstrated that there is a definite role for arthroscopic debridement in the management of SL, LT and TFCC tears.

Severe isolated trapezoid fracture: a case report.

Isolated trapezoid fractures are rare. We present a case of severe isolated trapezoid fracture associated with bone loss and proximal migration of the second metacarpal, which was treated successfully by open reduction and internal fixation with bone grafting and joint fusion.

Neuroma of the radial digital nerve of the middle finger following trigger release.

Trigger digit release is a common surgical procedure with a low complication rate. One of the potential complications is digital nerve injury. Though uncommon, digital nerve injury can be significantly symptomatic to the patient. We report a case of radial digital nerve neuroma formation following trigger release of the middle finger, which is considered to be safe, in terms of risk of digital nerve injury. We discuss our management of the complication, possible pitfalls which may have resulted in the complication in our case and offer possible means of overcoming these pitfalls.

Can a management pathway for chronic cough in children improve clinical outcomes: protocol for a multicentre evaluation.

BACKGROUND: Chronic cough is common and is associated with significant economic and human costs. While cough can be a problematic symptom without serious consequences, it could also reflect a serious underlying illness. Evidence shows that the management of chronic cough in children needs to be improved. Our study tests the hypothesis that the management of chronic cough in children with an evidence-based management pathway is feasible and reliable, and improves clinical outcomes. METHODS/DESIGN: We are conducting a multicentre randomised controlled trial based in respiratory clinics in 5 major Australian cities. Children (n = 250) fulfilling inclusion criteria (new patients with chronic cough) are randomised (allocation concealed) to the standardised clinical management pathway (specialist starts clinical pathway within 2 weeks) or usual care (existing care until review by specialist at 6 weeks). Cough diary, cough-specific quality of life (QOL) and generic QOL are collected at baseline and at 6, 10, 14, 26, and 52 weeks. Children are followed-up for 6 months after diagnosis and cough resolution (with at least monthly contact from study nurses). A random sample from each site will be independently examined to determine adherence to the pathway. Primary outcomes are group differences in QOL and proportion of children that are cough free at week 6. DISCUSSION: The clinical management pathway is based on data from Cochrane Reviews combined with collective clinical experience (250 doctor years). This study will provide additional evidence on the optimal management of chronic cough in children. TRIAL REGISTRATION: ACTRN12607000526471.

The oblique wedge osteotomy of the metacarpal condyle for reconstructing Wassel type IV thumb duplication in older children and adults.

In reconstructing the Wassel type IV thumb duplication in infants, a deviation deformity of the retained thumb may be corrected by a closing transverse wedge osteotomy of the metacarpal neck. In older children and adults, this technique may cause avascular necrosis of the retained metacarpal condyle. We have addressed this problem by using an oblique wedge osteotomy of the metacarpal condyle. Ten patients (mean age, 18.9 years) underwent this procedure between 1993 and 2007. Patients with deviation angles of 30° or less had a closing wedge osteotomy, while those with deviation angles exceeding 30° had a rotational bone graft osteotomy. Deviation angles were corrected from a mean of 32° (range, 16° to 55°) to 0° in eight thumbs and 10° in two thumbs. There were no cases of avascular necrosis. All patients achieved good results by Tada's criteria. This technique effectively restores bony alignment of the thumb and preserves vascularity of the retained condyle.