Dental clinicians may prescribe drugs less frequently than their medical colleagues, but the implications for a patient are the same.
Dental treatments often involve a combination of medical and surgical skills and to be effective, the dental team requires a thorough working knowledge of both the drugs that they can prescribe and those that the patient may already be taking on prescription from other members of the medical profession.
A failure to take proper account of both of these pharmaceutical considerations, when prescribing medication, could result in a disastrous outcome that is difficult to defend.
In this module, the terms 'prescribing' and 'prescription' will be used in their widest sense to include the administration of drugs by a clinician, the ordering of drugs to be provided to the patient by others (e.g. a pharmacy) and also the recommendation of drugs for the patient to obtain over-the-counter, and then to self-medicate.
The decision to prescribe
Every time a drug is prescribed or administered, a series of logical steps must be followed to ensure that a suitable selection is made. This logical sequence provides the justification for the prescription, should a complaint be made later about the decision.
The clinical records should contain sufficient contemporaneous information to allow any third party to review the decision some time later and to understand the rationale for the prescription.
The records should document, ideally verbatim, the patient's principal complaint on presentation along with a history of the condition. It is often useful to include what treatment the patient wants or expects to receive within this entry.
C/O; 'Abscess (indicates lower right) can't open mouth properly '- 'Just wants prescription' -'doesn't want any treatment today'
The clinical records should include a cumulative medical history, but it is imperative that the medical history is regularly reviewed with the patient.
Any changes need to be clearly documented in a dated entry. Notable changes, for example a new drug allergy or a new diagnosis (diabetes or cardiac disease) must be considered and recorded in a form that is accessible to all members of the dental team who may also need to know about such changes.
- Examination and special investigations:
A detailed note of the clinical findings and special investigations that have been performed will permit any reviewer to understand exactly how the differential diagnosis was reached. The differential diagnosis should be documented as well as the results of the special investigations, including radiographs that have contributed to it.
- Differential diagnosis and working diagnosis
Where there is doubt about the diagnosis, it is very helpful to record the differential diagnosis in the notes. It is important to be able to demonstrate that various alternative possibilities have been considered. They can be useful to refer to later, particularly if the provisional diagnosis turns out to be incorrect. When defending a clinician's prescribing decisions, it can be very helpful to know the thought processes that went into reaching the provisional diagnosis and the treatment plan.
A decision about treatment can only be made once there is a diagnosis. The treatment may be palliative/ advisory, medical, surgical or a combination of these and other approaches.
In each case the patient must provide a valid consent for the treatment proposed, and this requires the patient to be given sufficient information to assess the risks and benefits of each proposal, and where appropriate, the costs of each option.
Treatment desirable
Local rules
Once the decision has been made to treat the patient medically, the drug or drugs of choice can be selected.
Many drugs are available as over the counter medicines (OTC ). The remainder are prescription only medications (PoM). The range of OTC medicines varies from one jurisdiction to another and it is incumbent on any practitioner who might move between them in the course of their work, to familiarise themselves with the OTC medicines in every jurisdiction in which they practise . Just as prescribing rules can vary, so can the brand names of medicines. An international publication such as MIMS will be invaluable in assisting practitioners to resolve confusion about the names of medicines. With PoM, as with OTC , it is imperative that the prescribing clinician knows the brand name of the medicine as well as the generic name. The practitioner must be aware of the rules about prescribing in the particular jurisdiction, as these can also vary. Every jurisdiction has its own laws and the regulations about prescribing medicines can vary significantly. Ignorance of the local situation provides no defence when things go wrong.
Important considerations
The patient's records and current medical history must be reviewed and taken into consideration, especially their current medication and any previous allergies or interactions. The incorrect prescription of penicillin-type antibiotics to penicillin allergic patients is a mistake that occurs more commonly than might be imagined, as is the prescription of antibiotics and antifungals to patients currently taking coumarins such as warfarin. In these cases, which are often indefensible, a simple review of the medical history at the outset might well have avoided the adverse outcome.
Has the patient had this medication before? In order to be certain, check with the patient who, although prescribed the same drug before, may never have actually taken it.
Many medicines have side effects that are well documented and publicised. It is incumbent on the prescribing practitioner to know about these and to explain them to the patient. Equally, it is important to understand that other prescriptions may have side effects that are relevant and important in dental care, for example dry mouth associated with certain antidepressant medicines and gingival hyperplasia associated with anti-epileptics, anti-hypertensives and immunosuppressant medications. Be prepared to consult a reliable and up-to-date source of pharmaceutical data (e.g. MIMS or a national or local formulary or drug index) whenever a patient presents with a drug history or curious symptom. If in doubt, check.
The interaction between some antibiotics and the oral contraceptive pill (OCP ) is well documented, and therefore when prescribing amoxycillin for example, it is imperative that the notes can demonstrate that a woman of child bearing age has been asked whether or not she is using OCP , and if so, that she understands the risk of failure of the OCP because of the antibiotics. This discussion must be documented in the records, as the consequences of failure of the OCP for the woman may be serious and a claim in negligence may well be brought against the prescribing clinician.
Are you competent and permitted to prescribe the particular medicine?
In most jurisdictions there are restricted lists of medicines that can be prescribed by registered dentists, whilst in some countries dentists can freely prescribe any medicine. However any Dental Council/ Dental Board would be very concerned if any dentist were to issue a prescription for a medication whose effects might be beyond their training and competence.
If the prescription takes the form of a hand written instruction to a third party (such as a dispensing pharmacist), the generic name of the drug should be used and written in block capitals, in order to minimise the risk of a dispensing error. The dose should be clearly written missing out decimal points where they are not necessary and not abbreviating the units.
The frequency or interval between doses and duration of the prescription must be clearly legible, together with the total quantity to be dispensed.
The prescription should show the patient's name, clearly written, along with their address and (if required) their date of birth or age. The prescription should be signed and dated and the details of the prescription written in the patient's records as a contemporaneous entry. If the medicine is being dispensed as well as prescribed by the clinician, the dispensing record should be accurately maintained.
Computer-generated prescriptions also need careful monitoring.
Although the legibility of the written content is ensured, it is all too easy to select the wrong medicine from a menu of options with similar names, or to select the wrong, dose, frequency or route of administration. Therefore, computerised prescriptions need to be checked just as thoroughly as a handwritten prescription.
It goes without saying that it is a prerequisite of computerised prescribing, to ensure that you have identified the correct patient from the electronic database.
Consent
Whilst most clinicians appreciate that the patient must give their consent for every treatment, it is sometimes forgotten that the same process is necessary when prescribing medication.
In order for this consent to be valid, the patient must be offered all the information they need to reach a decision to give their consent. In many situations, a prescription for antibiotics or analgesics is an easy alternative for the practitioner-and the patient - where best practice might dictate that a more pro-active clinical intervention should be carried out e.g. extraction or pulp extirpation. Even though it might be more convenient and perhaps quicker to write a prescription, that patient might also like to know that an abscess for example, would resolve much more quickly and comfortably if endodontic treatment were to be commenced or local drainage achieved. Failure to discuss (or provide) this as an option might lead to a complaint that there was no valid consent for the medical treatment that was provided.
Having obtained a valid consent, it is important that the supporting discussion is clearly documented in the records. This should include the choices given to the patient and the risks/benefits described for each choice.
Review
When any course of medication is commenced, it is important to agree with the patient a period of time that should elapse before a review of the treatment and its effects is carried out. It is also important to advise patients of the likely timetable for improvement of their condition so that they can assess whether the review needs to be brought forward.
The medical treatment of trigeminal neuralgia or facial arthromyalgia through the prescription of appropriate drugs, will take a period of several weeks before any noticeable improvement is felt by the patient. In this situation the patient needs to be forewarned not to expect any immediate improvement.
They also need to understand that they will need to be reviewed within a reasonable timetable to discuss their condition before any repeat prescriptions can be organised.
Continuing professional development
There is a wealth of information about drugs and medicines available to the clinician, which begins with the basic training received at university, continues through in-service training in hospital practice or formal postgraduate courses and which needs to be updated throughout one's professional career.
Information is available from many other sources; data sheets and drug company representatives, articles in professional journals, internet research and personal study. It is important to be sure that the prescription you are writing is the currently accepted correct drug, dose, frequency and route for the particular condition.
Ultimately a Dental Council/Dental Board, the Courts or even a coroner at an inquest or fatal accident inquiry, can hold the prescribing clinician responsible for an adverse incident. Such clinicians could be called upon to explain the particular medicine that they chose.
Dentists should review critically any new drug that they decide to prescribe and always obtain the consent of the patient for its use. There are many useful sources of information available to practitioners via the published formularies and various online resources (including the Cochrane resource of evidence-based data)
Controlled drugs and legal considerations
Certain drugs are classified as being dangerous, or subject to restrictions regarding their possession, supply, use and storage. This varies from country to country and clinicians should familiarise themselves with the relevant local legal requirements and ensure that they comply with them. In any event, narcotic analgesics, sedative medicines and general anaesthetic agents are all attractive to thieves.
Ensure that any such drugs are stored according to the law with the proper records kept of their dispensing and disposal.
A formal controlled drug inventory is mandatory in most jurisdictions.
Who is the patient?
Prescriptions should only ever be considered if they form part of a bona-fide course of dental care and treatment. One Dental Council investigated complaints that a dentist was prescribing slimming tablets for his wife, because she could not obtain a repeat prescription from her medical practitioner; indeed the medical practitioner had declined to continue prescribing the medication.
The Dental Council was alerted to this prescription by the pharmacist who was asked to dispense the medication
It is not normally permitted to self-prescribe. Some Dental Councils have dealt firmly with dentists who have prescribed benzodiazepines for themselves in order to maintain a serious misuse habit. Once again, these prescriptions were brought to the attention of the Dental Council via the pharmacist who was asked to supply the drugs.
Summary
- Know what is required to be written on the prescription.
- Know the limits of prescribing.
- Never prescribe 'blind' - a diagnosis and provisional treatment plan should precede any prescription.
- Know the properties and risks of the medication that you prescribe.
- Prescribe appropriately and within your competence.
- Know the law and regulations about prescribing.
- Know the local law about dispensing medicines.
- Store all medicines safely and securely.
- Comply with the laws concerning controlled or dangerous drugs.