Dental providers and pharmacists: a call for enhanced interprofessional collaboration

Abstract

Reports concerning medication discrepancies in dental records indicate that the concept of interprofessional collaboration between the dental team and pharmacists should be considered at all educational levels in dentistry and pharmacy. Inclusion of oral health as a therapeutic area in didactic pharmacy curricula is needed. Early exposure of dental students and student pharmacists to collaborative practices through interprofessional educational experiences may create a higher degree of awareness of the role of each profession and the potential to improve patient outcomes. Furthermore, efforts are needed to develop a systematic approach for medication review and reconciliation in dental practice to obtain accurate medication lists, potentially by utilising health information technology.

In developed countries, prescribing of drugs is the most common form of medical treatment. The incidence of prescribed medication increases with increasing age, especially in persons over 60 years of age.

Globally, general pharmacology and clinical pharmacology is included in both pre- and postgraduate dental education. Prescribing of medications is often part of dental treatment, in addition to regular dental procedures. While rarely a major field of focus for most dentists, patients' medication use is often of great importance in oral health. It has been widely reported that numerous medications have a negative impact on clinical procedures through drug–drug interactions or adverse drug reactions affecting oral health¹. A common example is medication-induced salivary gland dysfunction, which may result from more than 1000 drugs. Xerostomia has been shown to lead to extra dental treatment and costs². Drug-induced gingival overgrowth (DIGO) may result from using calcium channel blockers (CCBs), and DIGO from CCBs is reported to result in three times higher occurrence of tooth loss and a considerably higher dental treatment cost, than that in patients not using CCBs³. Many classes of drug, including anticoagulants, anti-platelets and analgesics, may increase bleeding risk, which may affect dental procedures. Thus, dentists are challenged to continuously be informed and remain up to date on adverse drug reactions, drug interactions, antibiotic resistance and drug dependence.

There is currently discussion worldwide on antimicrobial resistance. Recent changes in antimicrobial guidelines have challenged dental providers to examine more carefully the risk–benefit relationship of antibiotics as prophylaxis, and international data suggest that overprescribing occurs4., 5., 6.. A recent pilot study in the USA suggests trends towards selection of inappropriate antimicrobials in dental practice⁷. The worldwide epidemic of opioid abuse and dependence has prompted reconsideration of existing prescribing patterns of opioid analgesics in the management of dental pain⁸.

As medication use is common in patients presenting to dental practices, it is of utmost importance for dental providers to evaluate each medication used by patients, including the potential for drug–drug interactions and oral adverse effects. However, for the dental practitioner to take necessary precautions regarding medication use, accurate medication lists that reflect actual medication use by patients must be readily available.

Discrepancies in general practitioners' (GPs') medication lists are common, and polypharmacy increases this risk⁹. These findings are consistent with data from the US, which report that medication discrepancies occur at an alarming rate in both inpatient and outpatient settings¹⁰. While several studies have demonstrated that GPs lack accurate medication records, data related to the accuracy of medication records in dentistry are sparse. However, two independent pilot investigations of interprofessional collaboration between dentists and pharmacists in the US and Norway have recently identified the presence of significant discrepancies between medication lists in the dental record and the medications that the patients are actually taking11., 12.. Choi et al.¹¹ found discrepancies in nearly 90% of medications in the dental record, compared with the medication list gathered by a pharmacist. Medication omission was the most frequent discrepancy (71.7%). Raknes et al.¹² reported that only 50% of medications used by dental patients were listed in the dental record. One of the main reasons for these discrepancies is identified by Valle-Oseguera and Boyce¹³: neither dentists or pharmacists are likely to have access to the patient's full medical record, including the complete medication list. In Norway, an electronic short version of patients' full medical records, called ‘The core journal’, has been introduced for medical personnel, with special focus on emergency situations, to improve patient safety during transitions of care¹⁴. However, dentists can only access this information after obtaining written consent from the patient. In most dental practices, the documented medication list is obtained through a written or verbal history provided by the patient, a method with inherent limitations. In the studies conducted by Choi et al.¹¹ and Raknes et al.¹², omissions of non-prescription therapies and natural medicines were frequent when the history was gathered by the dental provider using a patient report. Additionally, research suggests that patients, despite having knowledge of medication management support tools and methods, are not likely to use these when consulting a dental clinic¹⁵. While medication discrepancies were prevalent in both studies, Choi et al.¹⁶ found, in a follow-up study, that a pharmacist-led intervention resulted in a statistically significant reduction in the frequency of medication discrepancies and medication omissions. This intervention consisted of a pharmacist-designed prompt within the dental record to guide dental providers in conducting a focussed medication reconciliation and was coupled with a pharmacist-led educational session on collecting and updating accurate medication lists during patient encounters.

Interprofessional collaboration between pharmacists and dentists may provide solutions to these problems. In addition to being a specialist in oral health, dentists share an interest in improving the general health of their patients. Pharmacists may be a helpful partner in this work by providing dentists with updated information on changes in evidence-based guidelines and advice on potential side effects and interactions. A closer interprofessional relationship between these two groups may also encourage pharmacists working in community pharmacies to take a more active role as promoters of oral health, by assisting in self-care and over-the-counter medication use and referring people to dentists for both emergent and routine care¹⁷. We have found that the pharmacist–dentist partnership gives new and broader views on research and believe that this interprofessional alliance may lead to better practice and research, with the ultimate goal of increasing patient safety and improving care.

These preliminary reports concerning medication discrepancies in dental records indicate that interprofessional collaboration between the dental team and pharmacists should be initiated at all educational levels in dentistry and pharmacy. Inclusion of oral health as a therapeutic area in didactic pharmacy curricula is needed. Early exposure of dental students and student pharmacists to collaborative practices through interprofessional educational experiences may create a higher degree of awareness of each profession's role and the potential to improve patient outcomes. It may also be beneficial to include medical students in these experiences because of their pivotal role in prescribing. Furthermore, efforts are needed to develop a systematic approach for medication review and reconciliation in dental practice to obtain accurate medication lists, potentially by utilising health information technology.

Acknowledgement

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Conflict of interest

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Funding

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