Background/Rationale: Antibiotics and opioids are the top therapeutic categories prescribed by dentists. Interestingly, factors associated with prescribing behaviors of these medication classes are similar. Our preliminary data on dental prescribing demonstrates that 1) high prescribers of opioids are also high prescribers of antibiotics and 2) over-prescribing of antibiotics and opioids is common. However, there is a knowledge gap in our understanding of medication prescribing and overprescribing (for inappropriate indications and/or excessive quantity/potency/duration) by dentists. This gap is significant because dentists prescribe 1 out of every 10 prescriptions (Rx) for both antibiotics and opioids in the US. Inappropriate and appropriate use of antibiotic and opioids are a risk to patient safety, including: bacterial resistance, Clostridium difficile infection (CDI), opioid overdose, drug dependence and diversion. Opioid overprescribing is concerning because substance users commonly seek opioids from dentists, dentists infrequently use prescription drug monitoring programs (PDMP) and fatalities secondary to opioid use have been linked to dental prescribing. Use of antibiotics for infection prophylaxis prior to dental procedures has been associated with CDI. Guidelines for infective endocarditis and prosthetic joint infection prophylaxis during dental procedures were recently updated, significantly reducing the number of patients requiring antibiotic prophylaxis. However, despite infection prophylaxis being the primary indication for antibiotics prescribed by dentists, our national data shows only a small (0.7%) decrease in overall dental antibiotic prescribing. Although efforts are increasing to curtail overuse of these medication classes, most interventions are focused on medical providers.
Objective(s): Guided by preliminary data, we will be pursuing three specific aims: 1) Assess dental prescribing of antibiotics and opioid medications and identify characteristics associated with high rates of inappropriate prescribing; 2) Describe dentists' attitudes towards prescribing antibiotics and opioids among those with high and low prescribing patterns in high and low prescribing facilities; and 3) Develop a pilot implementation study to improve dental prescribing. The proposed study is aligned with the research priority areas of HSR&D (healthcare equity-vulnerable populations; implementation science-provider behavior; and patient-centered care-opioid use) and two White House National Action Plans focused on antibiotic resistance and adverse drug events. The goals of this collaborative project also align with the priorities of our operational partners: VA Dental Services, PBM MedSafe, and the Antimicrobial Stewardship Task Force.
Methods: We propose to conduct a mixed-methods study. Administrative data will assess antibiotic and opioid dental prescribing based on American Dental Association recommendations and identify factors related to prescribing. One-on-one qualitative interviews with 'high' and 'low'-prescribing dentists at 'high' and 'low'-prescribing facilities will assess perceptions of antibiotic and opioid prescribing, adverse drug events and facilitators and barriers to the use of prescribing resources. Non-VA sites are not included. We will triangulate our results to develop a pilot implementation project.
Findings/Results: The project start date is planned for July 1, 2018.
Impact: VA provides a unique opportunity to study dental prescribing because ICD9/10 coding by private sector dentists is rare. Thus, the impact of our results are likely to be far-reaching. This research is innovative in that it will be the first study, to our knowledge, utilizing national VA databases to answer research questions on dental prescribing of antibiotics and opioids. The goal of the project is to develop actionable findings for decision makers that can be implemented to improve evidence-based prescribing of antibiotics and opioids by dentists.
- Koppen L, Suda KJ, Rowan S, McGregor J, Evans CT. Dentists' prescribing of antibiotics and opioids to Medicare Part D beneficiaries: Medications of high impact to public health. Journal of the American Dental Association (1939). 2018 Aug 1; 149(8):721-730.
- Suda KJ, Henschel H, Patel U, Fitzpatrick MA, Evans CT. Use of Antibiotic Prophylaxis for Tooth Extractions, Dental Implants, and Periodontal Surgical Procedures. Open forum infectious diseases. 2018 Jan 1; 5(1):ofx250.
- Suda KJ. Antibiotic Prescribing in Dental Clinics. [Cyberseminar]. VHA Antimicrobial Stewardship Task Force. 2018 Jul 25.