Rational Prescribing

Practices and Prescription Writing

In Dentistry

Prescribing privileges are controlled by the state licensing boards

- Delegated powers by the state legislatures• Professions with prescribing privileges: Physician Dentist Podiatrist Veterinarian Optometrist Nurse Practitioner or Midwives Physician’s assistants Pharmacists

How are we different from Quacks? Does our training distinguish us?

Or is it because we use science in our clinical practice?

How much are we influenced by the medical representatives in our prescribing habits?

Ask these questions to yourself and search for honest answers.

we commonly prescribe antibiotics and analgesics.

How often are we aware why we prescribe a particular

antibiotic or pain-killer?

How much are we contributing to the problem of antibiotic resistance?

Have you ever asked yourself whether your

children be able to fight their infections in the future with so many resistant bacteria

around?

Too many commercials(companies). Too many drugs. Many Dosage forms. Too many generics for each drug

Rational use of drugs requires that patients receive medications :

Appropriate to their clinical needsclinical needs.In dosesdoses that meet their own

requirement For an adequate period of timeadequate period of time,,And at lowest cost lowest cost to them and their

community (WHO 1985).

Appropriate indication.Appropriate indication.

The decision to prescribe drug(s) is entirely based on medical rationale and that drug therapy is an effective and safe treatment

Appropriate drug.Appropriate drug. The selection of drugs is based on

efficacy.efficacy. safety.safety.Suitability.Suitability. cost considerations.cost considerations.Storage ConditionStorage Condition.

Appropriate patient.Appropriate patient.

No contra-indications contra-indications exist the adverse reactions adverse reactions is minimal, the drug is acceptable drug is acceptable to the patient.

Appropriate information.Appropriate information. regarding his or her condition and the

medication(s) that are prescribed. Patients should be provided with

relevant, relevant, accurate,accurate, important important clear informationclear information

Appropriate monitoring. Appropriate monitoring.

The anticipatedanticipated and unexpectedunexpected effects of medications should be appropriately appropriately monitored.monitored.

The number of drugs number of drugs per prescription is often more than neededmore than needed, with an average of 2.4 up to 10 drugs, while generally one or two drugs should be sufficient.

Wrong drWrong drug for a specific condition. Drugs of doubtful efficacy.of doubtful efficacy. Drugs of uncertain safety statusuncertain safety status. Use of drugs in wrong dosage wrong dosage and duration.duration.

In case of analgesics we need to know which one will be appropriate for patients needs so that he will get relief from his pain.

In case of antibiotics we should choose a proper antibiotic which will take care of his condition and assist his body in early resolution of his ailment.

We should also know exactly in which circumstances/ medical conditions preventive prophylactic cover is needed.

we have a professional responsibility for emergency dental care. When patients come with trauma, acute spread of infection, or hemorrhage, it is our duty to render treatment so that he gets relief in a reasonable time.

In many acute dental conditions, In many acute dental conditions, extirpation of the pulp or extraction of the extirpation of the pulp or extraction of the tooth will be necessary. tooth will be necessary.

Prescribing antibiotics is an adjunct in many such situations. When it is clinically indicated, it is definitely of therapeutic benefit to the patient.

According to the American Dental According to the American Dental Association, the following guidelines should Association, the following guidelines should be observed when prescribing antibacterial be observed when prescribing antibacterial drugs:drugs:

But systemic antibiotics systemic antibiotics should be used with caution because of the possibility of toxicity,toxicity, side effectsside effects, the development of resistant development of resistant strains of microbes, and allergic and allergic reactions.

1- Make an accurate diagnosis;accurate diagnosis;2- Use appropriate antibiotics appropriate antibiotics and dosing dosing

schedules;schedules;3- Consider using narrow-spectrum narrow-spectrum antibacterial

drugs (Clindamycin, Metronidazole, penicillin V Potassium) in simple infections simple infections to minimize disturbance of the normal micro flora, and preserve the use of broad-spectrum drugs broad-spectrum drugs (ampicillin, amoxicillin, erythromycin, tetracycline, etc.,) for more complex infections

4- Avoid unnecessary use unnecessary use of antibacterial drugs in treating viral infections;

5 - If treating empiricallyempirically, revise treatment regimen based on patient progress or test results;

6 - Obtain thorough knowledge knowledge of the side effects side effects and drug interactions of drug interactions of an antibacterial drug before prescribing it;

7 - Educate the patient regarding proper use of the drug and stress the importance of completing the full course of therapy full course of therapy (that is, taking all doses for the prescribed treatment time).

American Academy of Pediatric Dentistry (AAPD) has given recommendations for clinical guideline on appropriate use of antibiotic therapy.

Conservative use of antibiotics is indicated to Conservative use of antibiotics is indicated to minimize the risk of developing resistance to minimize the risk of developing resistance to current antibiotic regimenscurrent antibiotic regimens.

Whenever an antibiotic is prescribed to a female patient female patient taking oral contraceptives contraceptives to prevent pregnancy, the patient must be advised to use additional techniques of birth additional techniques of birth control during antibiotic therapy control during antibiotic therapy and for at least 1 week beyond the last dose as the antibiotic may render the oral contraceptive antibiotic may render the oral contraceptive ineffective.ineffective.

American Academy of Pediatric Dentistry recommends the following general principles when prescribing antibiotics for the pediatric population.

When a child presents with a facial swelling a facial swelling secondary to a dental infection, he should receive immediate dental attention.

Depending on clinical findings, treatment may consist of treating or extracting extracting the tooth/teeth in question with antibiotic antibiotic coverage.coverage.

Severity of the infectionSeverity of the infection, the ability to obtain ability to obtain adequate anesthesiaadequate anesthesia, and the medical status medical status of the child of the child should be taken into consideration.

Bacteria can gain access to the pulpal tissue pulpal tissue through caries, exposed pulp or dentinal tubules, cracks into the dentincracks into the dentin, and defective defective restorations.restorations.

While rendering treatments like pulpotomypulpotomy, pulpectomypulpectomy, or extractionextraction, antibiotic therapy antibiotic therapy usually is not indicated

If the dental infection is contained within the pulpal tissue pulpal tissue or the immediately surrounding tissue. In such a case, there will be no systemic signs of an infection (i.e., no fever and no facial swelling).

Viral conditions such as acute primary herpetic gingivostomatitis herpetic gingivostomatitis should not be treated with antibiotic therapy unless there is strong evidence to indicate that a secondary bacterial infection exists.

Analgesics are another group of drugs commonly prescribed by dentists.

Our pain management goals should be:

Pain Management GoalsPain Management Goals

To maintain maximal patient comfort.To maintain maximal patient comfort.To minimize unwanted drug side effects. To minimize unwanted drug side effects. To rapidly return injured tissue to function.To rapidly return injured tissue to function.

Pre-procedural analgesia can be employed for delaying the onset of postoperative pain and to reduce its magnitude.

But it has disadvantages like GI upset in patient with empty stomach and GI upset in anxious patient.

Ibuprofen 400mg ½ hour before appointment can be prescribed for this purpose.

Step 1: Define the patient’s problem Make specific & Accurate diagnosis.Make specific & Accurate diagnosis.

Step 2:Consider the pathophysiological implication of the diagnosis

Step 3: Specify the therapeutic objective .

Step 4: Select the Drug of choiceStep 5: Determine the appropriate dosing

regimen.Step 6: Devise a plan for monitoring the

drug’s action and determine an end point for therapy.

Step 5: Give information, instructions and warnings (patient education).

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American Academy of Pediatric Dentistry (AAPD). Clinical guideline on appropriate use of antibiotic therapy for pediatric dental patients. Chicago (IL): American Academy of Pediatric Dentistry (AAPD); 2005. 3 p.

ADA Association report ; J Am Dent Assoc, Vol 135, No 4, 484-487. © 2004 The American Dental Association

Marcos Luciano Pimenta Pinheiro, Filipe Polese Branco, Maria Cristina Volpato, Eduardo Dias de Andrade: Analgesic choice in dentistryPart II : The toxicity: Braz J Oral Sci. October-December 2005 - Vol. 4 - Number 15

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Basic & Clinical Pharmacology, 12th Edition Bertram G. Katzung, Susan B. Masters, Anthony J. Trevor