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 .

Candida virulence and ethanol-derived acetaldehyde production in oral cancer and non-cancer subjects.

OBJECTIVES: To compare biofilm-forming ability, hydrolytic enzymes and ethanol-derived acetaldehyde production of oral Candida isolated from the patients with oral cancer and matched non-oral cancer. MATERIAL AND METHODS: Fungal biofilms were grown in RPMI-1640 medium, and biofilm mass and biofilm activity were assessed using crystal violet staining and XTT salt reduction assays, respectively. Phospholipase, proteinase, and esterase production were measured using agar plate method, while fungal acetaldehyde production was assessed via gas chromatography. RESULTS: Candida isolated from patients with oral cancer demonstrated significantly higher biofilm mass (P = 0.031), biofilm metabolic activity (P < 0.001), phospholipase (P = 0.002), and proteinase (P = 0.0159) activity than isolates from patients with non-oral cancer. High ethanol-derived acetaldehyde-producing Candida were more prevalent in patients with oral cancer than non-oral cancer (P = 0.01). In univariate regression analysis, high biofilm mass (P = 0.03) and biofilm metabolic activity (P < 0.001), high phospholipase (P = 0.003), and acetaldehyde production ability (0.01) were significant risk factors for oral cancer; while in the multivariate regression analysis, high biofilm activity (0.01) and phospholipase (P = 0.01) were significantly positive influencing factors on oral cancer. CONCLUSION: These data suggest a significant positive association between the ability of Candida isolates to form biofilms, to produce hydrolytic enzymes, and to metabolize alcohol to acetaldehyde with their ability to promote oral cancer development.

Urban legends series: oral candidosis.

Candida species (spp) are commensal yeast that can only instigate oral infection (oral candidosis - OC) when there is an underlying predisposing condition in the host. We investigated four controversial topics on OC: (i) How can a microbiological determination of OC be made as Candida spp. are commensal yeasts and not all of them form hyphae or pseudohyphae during infection? (ii) Is median rhomboid glossitis (MRG) a manifestation of candidal infection? (iii) Can candidal infection cause palate papillary hyperplasia (PPH)? (iv) What is the best therapeutic treatment for denture-associated erythematous stomatitis (DAES)? Results from extensive literature searches, including a systematic review, suggested the following: (i) the diagnosis of OC merely on the basis of the presence of yeasts is an oversimplification of a complex process. No convincing evidence of a single test or method better able to discriminate the transition from candidal saprophytism to pathogenicity has been reported in the literature; (ii-iii) conclusive evidence of a direct aetiopathogenic relationship between MRG and PPH and candidal infection has not been found; and (iv) only limited evidence is available for any DAES treatment, thus making it impossible to make strong therapeutic recommendations.

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.

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.

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.

Direct allelic variation scanning of the yeast genome.

As more genomes are sequenced, the identification and characterization of the causes of heritable variation within a species will be increasingly important. It is demonstrated that allelic variation in any two isolates of a species can be scanned, mapped, and scored directly and efficiently without allele-specific polymerase chain reaction, without creating new strains or constructs, and without knowing the specific nature of the variation. A total of 3714 biallelic markers, spaced about every 3.5 kilobases, were identified by analyzing the patterns obtained when total genomic DNA from two different strains of yeast was hybridized to high-density oligonucleotide arrays. The markers were then used to simultaneously map a multidrug-resistance locus and four other loci with high resolution (11 to 64 kilobases).

Molecular epidemiology of global Candida dubliniensis isolates utilizing genomic-wide, co-dominant, PCR-based markers for strain delineation.

The molecular epidemiology of Candida dubliniensis has been studied using large complex DNA probes for Southern analysis and has revealed the existence of distinct genotypes within this species. The aim of the present study was to utilize a PCR-based analysis of molecular co-dominant markers to assess the relatedness of a global and temporally diverse collection of well characterized isolates of C. dubliniensis. Sixty-two C. dubliniensis strains were collected from the authors of previously published studies. Co-dominant PCR-based markers utilizing five separate PCR fingerprints were obtained in the present investigation. Phylogenetic and statistical analyses utilizing permutation tests were undertaken to assess correlations amongst the isolates. Three distinct PCR-groups were observed and there was evidence that strains isolated since 1990 were genotypically more similar to each other than they were to strains recovered prior to 1990.

Surgical management of recurrent TMJ dislocation-a systematic review.

PURPOSE: Recurrent temporomandibular joint (TMJ) dislocation can be challenging to treat and the current understanding regarding aetiology and management of this condition is limited. The aim of this paper was to conduct a systematic review regarding the management of recurrent TMJ dislocation. METHODS: A literature review was conducted using PRISMA guidelines to identify papers published between 2006 and 2016. The resultant papers were analysed. RESULTS: A total of 33 papers were found relevant to the study. Minimally invasive techniques described included autologous blood injection, which was associated with an overall success of 80% at 12 months. Other modalities investigated included OK-432 sclerotherapy, laser capsulorrhaphy, botulinum toxin of the lateral pterygoid muscle or modified dextrose. These publications show promising success rates. Surgical techniques described included disc plication, eminoplasty and eminectomy. These modalities had a similar success rate, although numbers were limited. The true incidence of recurrent TMJ dislocation is unknown and aetiology is limited to expert opinion. CONCLUSION: The current understanding of management for recurrent TMJ dislocation is limited to case series and case reports. This paper compiles the current understanding of management of recurrent TMJ dislocation. Compared to previous reviews, this paper describes some novel minimally invasive techniques with promising success in the management of recurrent TMJ dislocation.

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.

Local adverse effects of amalgam restorations.

Amalgam has been used for the restoration of teeth for well over 100 years, and is the most successful of the direct restorative materials with respect to longevity. Despite the increasing use of tooth-coloured materials, with advantages of aesthetics and adhesion, amalgam is one of the most widely used dental restorative materials. One of the principal disadvantages of amalgam, apart from aesthetics, is that it may have adverse biological effects, both locally and systemically. Locally, it can cause an erythematous lesion on the adjacent oral soft tissues (tongue and buccal mucosa), and systemically free mercury in the amalgam may give rise to a hypersensitivity reaction. The purpose of this paper is to review the literature concerning the local adverse reactions to dental amalgam. The focus will be on the reactions of the oral mucosa, and brief consideration will be given to laboratory cytotoxicity of dental amalgam and its components, and to the 'amalgam tattoo'.

Oral cancer awareness for the general practitioner: new approaches to patient care.

In Australia, oral cancer accounts for approximately 2-3 per cent of all cancers, and approximately 1 per cent of deaths from cancer. The incidence of intra-oral cancer is gradually increasing. It is now well established that early detection of potentially malignant disease can improve the clinical outcome for patients, and as such it is the responsibility of dentists to identify such lesions early. To facilitate early detection of suspicious oral lesions several clinical methods of detection can be used. In addition to conventional visual screening of oral tissues with the naked eye under projected incandescent or halogen illumination, there are many clinical diagnostic aids that can be undertaken to help detect oral cancer. In this article we explore clinically available modalities that may be used by the general dental practitioner, and highlight their inherent strengths and weaknesses.

The role of alcohol in oral carcinogenesis with particular reference to alcohol-containing mouthwashes.

Worldwide, oral cancer represents approximately 5 per cent of all malignant lesions, with over 800 new intra-oral squamous cell carcinomas registered in Australia each year. Despite recent advances in therapy, the five-year survival rate remains around 50 per cent and the sequelae of treatment can be seriously debilitating. It has been long established that smoking and alcohol consumption are risk factors linked to the development of oral cancer. This review assesses the epidemiological evidence, supportive in vitro studies and mechanism by which alcohol is involved in the development of oral cancer. Further, we review the literature that associates alcohol-containing mouthwashes and oral cancer. On the basis of this review, we believe that there is now sufficient evidence to accept the proposition that alcohol-containing mouthwashes contribute to the increased risk of development of oral cancer and further feel that it is inadvisable for oral healthcare professionals to recommend the long-term use of alcohol-containing mouthwashes.

Surgical management of recurrent dislocation of the temporomandibular joint: a new treatment protocol.

Recurrent dislocation of the temporomandibular joint (TMJ) is rare. It is distinct from acute or chronic dislocation and is associated with considerable morbidity and deterioration in quality of life. To formulate a practical surgical treatment algorithm, we retrospectively reviewed the management and long-term outcomes of 14 patients who presented to a single hospital department over a period of six years (2010-2016), and collected data on demographics, clinical features, operation, and outcome. Patients were followed up for a minimum of 12 months and a maximum of seven years. Results showed effective long-term resolution of symptoms after a combination of eminectomy and disc plication (meniscopexy). Patients whose symptoms had resulted from dystonia of the lateral pterygoid muscle also benefitted from additional lateral pterygoid myotomy. A combination of eminectomy and disc plication (meniscopexy) effectively provides successful long-term outcomes in this group of patients.

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.

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.

A blinded randomized controlled trial comparing lignocaine and placebo administration to the palate for removal of maxillary third molars.

Routine use of a palatal injection for the removal of maxillary third molars has never been validated. The purpose of this blinded, randomized, controlled trial was to assess the requirement of a separate palatal injection for the extraction of maxillary third molars. Fifty-one patients requiring the removal of bilateral maxillary third molars were enrolled. Each patient acting as their own control received buccal infiltrations of lignocaine bilaterally, then 0.2 mL of lignocaine without vasoconstrictor was administered to one side of the palate and the same amount of normal saline administered to the other side. Sides were randomized as to the active ingredient and both the patient and operator were blinded. All extractions were performed by a single operator using a consistent technique and no additional sedative or anaesthetic agents were utilized. Data relating to the pain of the extractions and of the palatal injection were obtained on a Visual Analogue Scale (VAS). Verbal Response Scale (VRS) data were obtained additionally for a subset of 21 patients. Statistical analysis confirmed clinical equivalence between saline and lignocaine to the palate (95% CI -1.7 to 6.2mm, equivalence range -6.75 to 6.75 mm). No patients requested additional lignocaine to the palate in order to ensure comfortable extraction. This study provides evidence that the poorly tolerated palatal injection of local anaesthetic for the removal of maxillary third molars may not be required.

Evaluation of two dental identification computer systems: DAVID and WinID3.

Human identification, by comparing dental characteristics, is considered to be one of the most reliable, accurate and rapid methods of resolving the identity of visually un-identifiable deceased persons. In recent decades computer programs have evolved to aid odontologists by suggesting records that have similar dental features. The aim of the present study was to compare two of those programs; Disaster And Victim IDentification (DAVID) and WinID3 in terms of effectiveness, accuracy and speed of data entry and to further compare them with the efficiency of the classical method of manually matching postmortem and antemortem dental records. An open disaster was simulated whereby 52 fragmented remains made of acrylic replicas and 77 provisional victims were represented on Interpol F2 postmortem and antemortem forms. The results assessed were the first seven possible matches made by each program. Manual matching of dental characteristics performed better than both programs (P<0.001) yielding 29 identifications. Eleven and six positive matches were the result of the DAVID and the WinID3 programs respectively (P=0.185). Data entry was quicker for WinID3. It was concluded that both programs are still not as accurate as the time-consuming manual matching method. The difference in performance between the DAVID and the WinID3 programs was attributed to the inclusion of more comparable dental characteristics, the inclusion of the type of dentition (deciduous or permanent) and the weighting of those characteristics by the DAVID program.

Palatal anaesthesia for the removal of maxillary third molars as practised by oral and maxillofacial surgeons in Australia and New Zealand.

BACKGROUND: Injections of local anaesthetic to the palate are well known to be poorly tolerated. The absolute requirement of a palatal injection for the removal of maxillary third molars has never been investigated. The aim of this study was to document the current practice of palatal anaesthesia for extraction of these teeth with local anaesthesia as practised by oral and maxillofacial surgeons. METHODS: A postal survey was sent via the ANZAOMS office to all oral and maxillofacial surgeons who were members of the Australian and New Zealand Association, a total of 131. A response rate of 64 per cent (n = 84) was achieved. The frequency of administration and the factors that determined the decision to administer a palatal injection were assessed, as well as the methods employed for reducing the injection discomfort. RESULTS: The majority (77 of the 84) "always" gave a palatal injection for the removal of maxillary third molars, four respondents administered an injection "most of the time", and two respondents "occasionally". Significantly, one respondent "never" gave a palatal injection. The majority (76 per cent) utilized at least one adjunct in order to reduce the discomfort of the injection. CONCLUSIONS: The results of this survey suggest that for removal of maxillary third molars the requirement of the poorly tolerated palatal injection may not be absolute as conventionally taught and demonstrates the need for further investigation.

Oral candidal carriage in asymptomatic patients.

BACKGROUND: Interest in the association between oral cancer risk and Candida-associated promotion of mucosal dysplasia continues. However, little is known of the presence and amount of oral yeast in the mouths of healthy patients without mucosal lesions. The purpose of this prospective cross-sectional clinical study was to ascertain the prevalence and degree of carriage of Candida in the oral cavities of a non-cancer population, with reference to a range of parameters affecting the oral environment. METHODS: Oral rinse samples were collected from a sample of 203 patients attending the Royal Dental Hospital of Melbourne and analysed for the presence and degree of colonization of yeast species that were phenotypically identified as albicans and non-albicans species. RESULTS: Oral yeast carriage was found in 98/203 patients (48.3%), and of these, 83 (84.7%) patients carried C. albicans. There was no statistical difference in carriage when comparing gender, age, or presence of a removable prosthesis. CONCLUSIONS: Both smoking and the presence of active carious lesions were found to be positively correlated with the carriage of oral Candida. Individuals who are current smokers are nearly seven times more likely to have oral Candida, and participants with high candidal colonization are more likely to be current smokers. Participants with active carious lesions were also more likely to carry oral Candida.