Melbourne Dental School - Theses
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ItemDental therapeutic guideline adherence in Australia( 2020)Background: Dentists prescribe a variety of medicines, the most common being antibiotics, analgesics and anxiolytics. Drugs have a limited role in dentistry, usually being recommended as an adjunct to dental treatment. In Australia, the Therapeutic Guidelines Oral and Dental are the national prescribing guidelines. Literature shows that dentists worldwide tend to overprescribe antibiotics and do not prescribe in accordance with guidelines. The aims of this thesis were to establish current dental prescribing patterns, determine reasons behind and influences on prescribing decisions, and to design and implement a targeted intervention to optimise dental prescribing. Methods: A three-phase project was conducted. In Phase 1, publicly available data on dispensed dental medicines (2013-2016) was accessed from the Department of Health to analyse dental prescribing trends in Australia. Phase 2 involved two studies of dentists to determine reasons for prescribing decisions: 1. postal survey (n=1,468; response rate=26%) of dentists in Victoria and Queensland and 2. individual qualitative interviews (n=15) of dentists in Victoria. Phase 3 involved designing and conducting a pilot intervention with the aim of improving prescribing. The intervention comprised targeted education and a dental-specific clinical-decision prescribing tool. Participants (n=26) self-recorded their prescriptions for 12 weeks, with the intervention delivered at the six-week mark. Effectiveness was evaluated by comparing total number of prescriptions, indications for prescribing and prescription regimens before and after the intervention. Results: Phase 1 (Chapter 3): Dentists in Australia make some inappropriate prescribing choices, and prefer moderate- to broad-spectrum antibiotics over more appropriate narrow spectrum options, as recommended in the guidelines. The use of opioids and benzodiazepines increased over the study period, indicating need for more education about abuse potential as well as the appropriate role of opioids in dental pain. Phase 2 (Chapter 4): Antibiotics were overprescribed in approximately 55% of cases. Between 16-27% of dentists would preference other analgesics over NSAIDs for dental pain, and almost half (46%) of the participants who prescribed anxiolytics did so inappropriately, with regimens and choices outside the guidelines. Surveys showed a significant proportion of dentists tended to overprescribe antibiotics, prescribe for incorrect clinical indications and inappropriately preference other analgesics and opioids for dental pain over NSAIDs. Several non-clinical factors, such as time pressure and patient expectations, influenced prescribing. Phase 3 (Chapters 5 and 6): Comparing prescribing after the intervention to before revealed a 41% reduction in prescribing of antibiotics and a 45% reduction in inappropriate prescribing. Prescribing of paracetamol/codeine reduced by 57%. For the three most commonly prescribed antibiotics (amoxicillin, metronidazole and phenoxymethylpenicillin), there was an improvement in the accuracy of prescriptions ranging from 0-65% to 75-100% using Australian therapeutic guidelines as reference. Conclusions: Australian dentists overprescribe antibiotics; many factors that influence prescribing (both clinical and non-clinical). Data on prescribing choices and reasons for inappropriate prescribing can inform future dental education and the development of stewardship programs for dental practice. Targeted interventions addressing specific misconceptions and areas that are lacking can produce positive changes with public health benefits. The context-specific intervention that was developed shows substantial promise for implementation into dental practice.