Dentists and Prescriptions

I am curious about prescription rights also. Are dentist limited as to what they can prescribe. I think they can administer anxiolitics to patients while they are treated.

 

i am pretty sure that dentists have full prescription rights. nevertheless, a pharmacist may not fill out a script for for a B-blocker written by a dentist- that would be pretty suspect. some anti-depressants though (although I know you were just giving an example) would seem to fit well within dental prescribing rights, as many (paxil) have been shown have better anxiolitic effects than benzo's. but anibiotics, antifungals, seditives (oral or IV, IM), benzo's, antivirals, and obviously locals are all fair game.

 

Of course they have full prescription rights. It just wouldn't be feasible to grant "partial" prescription rights. Medicine and dentistry change quickly; the drugs available change quickly. To allow the federal bureaucracy to regulate which prescriptions were appropriate coming from any given specialist would be a disaster. We would be decades behind where we are now.

 

MD's, DO's, DPM's and DDS's can prescribe what they may. Of course, the pharm may refuse to fill a prescription (for any of the previously mentioned degrees), but the right to prescribe is there.

 

My DEA number lets me prescribe ANY drug(except for Schedule I experiemntal drugs and thats simply because I didn't check that box off on the form) that I want to. Do I, no, no, no. Can I, you bet.

Typically you'll find that you'll regularly write for 12-15 drugs. My basic ones are
Antibitoics(Pen VK, Amoxicillin, Clindamycin and E-mycin)
Pain Meds(Vicodin, Darvocet, Ultram and Tylenol #3)
Muscle Relaxants(Flexeril and Robaxin)
Histamine Blockers(Allegra and Clarinex)
Pysch Meds(Amytryptolline - go see a TMJ course by Dr. Jeff Okeson and you'll see where this comes into play)
Sedatives(Valium and Xanax)

90% of the scripts I write are antbiotics and pain meds though. Sure, I'll admit, I've written scripts for inhalers for my wife. I've written scripts for cough medicine and antibiotic eye drops for my partners kids, and even once for one of my hygenists birth control pills, and the pharmacist has never callled. As a matter of fact, about the only time the pharmacist will call is if your writing a script for a narcotic for someone they suspect is a drug abuser(I.E. you're the 5th different doc to give them Vicodin in the last few weeks), or if one of your scripts shows up for an "uncommon" narcotic pain med from your office(for example, my 2 narcotic pain meds that I almost always write for are Vicodin and Darvocet, and the 6 or 7 main pharmacies around my office where most of my patients go have this on record, as well as the fact that I will ususally dispense between 10 and 25 pills with no refills. So if they see a script from me for 50 Percocet with 5 refillls, they'll call me and ask if I really wrote it)

As a liscensed dentist, you will pay the same fee to the DEA ($210 for 3 years at my last renewal) as your medical colleagues, and this gives you all of the same priviledges as them. So when you get your DEA#, if your long time desire is to write a script for Viagra, go ahead and make sure that your scrub bottoms aren't too tight that day!

 

So if dentists are allowed to prescribe everything an MD can, why havent they branched out and started treating non-dental problems?

apparently there are no legal issues involved

 

Well, there's the matter of malpractice.

 

There is also that little thing of ethics and the hippocratic oath that we take with the do no harm clause. By the time you graduate dental school, one would hope that you have enough sense to know where your resonable limits are, this is one of those.

I've had many patients ask me if I can write them a prescription for their regualr MD prescribed meds because "it's too tough to see my regular doctor" and I've cordually refused ever time. The only time that I stray from that is in my forementioned situations where I have complete and total knowledge of not only the patient, but also the situation.

 

To add to Dr. Jeff's wise post: writing a prescription is only part (and usually a small one!) of treating a disease or infection.

Just because dentists can prescribe anything, doesn't mean it is in the patient's best interest to do so.

 

I think TCA's for chronic pain may be fair game, but certainly Inhalers or oral contraceptives are not. Furthermore, using Paxil as an anxiolytic is certainly not appropriate in the dental setting (open a pharmacology textbook to see why). A DEA license may cost the same for DMD's and MD's but that argument doesn't hold any water when it comes to what one is competent to prescribe. Pharmacists may be inclined to dispense non-conventional dentist-written prescriptions, but in no way is that the standard to which dentists must abide. The medical standard would be the more obvious and appropriate way to judge what you can or cannot dish out to the unsuspecting public. Consider the following:

When writing a script for oral contraceptives, do you follow the patients lipid profile as is medically required? Do you screen for hypercoagulable states? (Factor V Leiden mutation which is extremely common, added to oral contraceptives is a lethal combo). How about liver enzymes? Check GGOT AST/ALT for occult borderline liver function? Also, do you do a gynecological exam, as is almost always done before any women receives OCP's (I think not). Even if its for your wife, just because you know her, doesnt mean you medically can justify that prescription, nor can your friendly neighborhood pharmacist.

For a an Inhaler (presumably a Beta agonist), among other things did you check the patients blood sugar, screen for diabetes as you MUST when handing out inhalers? Simply asking the patient "did you have diabetes" is not enough. Do you know what can happen to a diabetic on Albuterol? Once again, just knowing them or asking isnt enough. There are many un Dx'ed diabeteics out there walking around with blood sugar levels of 300 w/o Sx!! Put them on albuterol, and it will be the forensic pathologist who makes the DX!
The correct management of asthma is complex when done properly by a specialist, the choice and sequence of inhalers is not a simple matter.

For the patients well being, I think its best to do a team approach with an MD, always. The pharmacist's judgement is almost completely irrelevant when it comes down to what really matters, patient safety. Pharmacists may have a superficial role, and serve as a screener for interactions, but not medical utility.

 

Hmmmm, sounds like someone is a second year med student studying for their USMLE. I have received presciptions for beta-agonist inhalers from numerous MDs, and none of them ever took a blood test to screen for diabetes (even at the allergist's office). They usually just ask which one I took and proceed to rewrite the script. As far as what kind of drug interactions could happen when albuterol is given to a diabetic, we do own PDRs in our dental offices and if a dentist was concerned, s/he could look it up.

I looked up both BCP and beta-agonist inhalers in the pharmacology lectures we had, and there was no mention of Factor V Leiden mutation or diabetes as red flags with these drugs. Then again, maybe our pharm course (administered and given entirely by medical school professors) isn't the most comprehensive. Makes you wonder b/c our MD students are receiving similar pharm lectures. Not that it isn't important, you just taught me a thing or two for my pharm boards this fall (dental students have pharm on the part II boards senior year). I'd look the drugs up in my PDR, but I left it in clinic.

The point was, dentists could prescribe these medications if they had to and had good reason to do so. If something happened to a patient while they were on ANY medication given by the dentist (or MD), you could bet there would be serious consequences for the dentist, whether or not it was a "traditional" medication prescribed by dentists or an "unusual" one.

BTW Dr. Jeff, I thought there were laws in place so you couldn't prescribe meds to family members. Or is that a state law thing, something we do in New York state?

 

In general as long as you're not prescribing a narcotic to a family member, its a non issue. In many cases even if you are writing a narcotic for a family member its a non-issue(I personally haven't, but one of my general surgeon colleagues I know wrote for a narcotic after his wife broke her arm without any pharmacy related issues).

If 1neuro1 had read my previous post a little closer about an inhaler for my wife and some BCP's for one of my hygenists, the statement I made later on about these being very rare, specific instances where I had very detailed knowledge of not only the patients health, but also ALL the cicumstances surrounding each situation should have seemed apparent. Also, I later stated that I will ALWAYS refuse to refill one of my regular patients Rx's, and instead allow their MD to take care of that. BTW, how many MD's will check every possible lab test/value prior to calling in a refill. I bet that many MD's will only become aware of most everyday med refills(i.e. inhalers/BCP's/anti-histamines/NSAID's/Diuretics) AFTER the ofice manager has called in the authorization for a refill to the pharmacy

The practices that you'r etaught in the hallowed halls of dental/med school are often very different(and antiquated) compared to real world practice. I'm not saying that its a privilege that warrants abusing, but the statement "common things happen commonly" does apply, and you'll see that in real life there is a great deal of similarity between patients and their presentation, care and treatment modalities.

 

#1
Factor V Leiden mutation is the most common cause of hypercoagulable states, some studies put it as high as 15% of the general population, and over 60% of those with DVT's. I would think a dental pharm lecture is one place to go for that kind of material. I guess they didnt teach you guys that, or the scribe missed it. Factor V Leiden mutation has several paragraphs devoted to it in any textbook of pathology, internal medicine, or critical care. I'm suprised it isnt all over your review books. This may illustrate the fact that dental education is very different from a medical eduaction. There is some overlap, but dentists need to know a lot more in some areas, a lot less in others. A 3rd year med student would probably destroy a whole set of teeth with one click of the drill, and likewise a 3rd year dental student would not know where to even start in the ICU.

#2
I could give my 13 yr old nephew a PDR and have them look up drugs as well, can he prescribe some coumarin now? The old look it up excuse is overused. I dont want any doc taking care of me to have to look things up as he's writing the script. Some things should be known. Guess what, not everything is in PDR. Its a factbook published by the drug manufacturers, not a How-To -Manual of medicine. Although many attempt to use it that way.

#3
The sad thing is most docs in private practice do miss a lot, dont order labs when they should, and hand out drugs just assuming everything is ok. These are the guys who end up killing or hurting patients every once and a while, and jacking up malpractice costs for all of us. Most of the time all ends up ok, and they get things done faster and make more money. When they get sued (and they all do) they clean up their act for a few years and then start being lax again. I just think there should be a higher standard.

At a teaching hospital, they dont usually operate in that manner, and you do catch contraindications and interactions before they happen---this is much mroe common than you would think! Just because certain docs are lax with the rules and can get away with it 98% of the time doesnt mean the dental profession can start writing scripts beyond the scope of their practice. "you -should have- known better" is different from "you -didnt- know any better". Its all relative.

#4
Common things happen commonly is a very good way to put it. OCPs and Inhalers are certainly common. So is malpractice. Irreversible pulpitis is also a common thing, but I wouldnt know how to spot it, or even begin to comprehend it. I certainly wouldnt dare treat it, not even if it were my wife. I' d drive her to see the endodontist, thats the limit of my expertise. These things are best left to the experts. This way, the patient always gets the best possible care, even if it may be inconvenient this is what its all about.

 

1Neuro1,

No, the scribe did not miss it; we don't have a note-taking service at my school. They give us the notes, or you take your own. I looked again, here's what the department notes said "Side effects of oral contraceptives include...venous thrombosis and embolism..." That's exactly how it's written. And, if you had read my post, our pharm course is taught by the med school and is very similar to the med student pharm course.

I own over 100 medical and dental textbooks on DVD; I did a search for "Leiden" and got 3 hits each in Robbin's pathology book (we used this book for our path course, which was taken with the med students) and Goodman's pharm book and over 36 hits in Harrison's book of internal medicine. So the only book with several paragraphs on it is the Internal Medicine book. The 15-fold risk you mention is in Harrison's.

I also own a copy of First Aid for the USMLE; in there it says a drug reaction to oral contraceptives is thrombotic complications. That's the only mention of it in there. I haven't looked at any pharm review books yet, so I couldn't tell you if it's in there.

So much for the factor V Leiden deficiency. If I saw it on my board exam, I'd probably make the connection between venous thrombosis and factor V being in the coagulation pathway somewhere and possibly pick the right answer. (After all this, I hope it shows up on my board exam). But I am not planning on prescribing BCP, that's why you are in med school.

I'm not saying that this interaction is not important. But I don't want you thinking we are idiots who think nothing of prescribing medications. We know there are consequences to anything we might prescribe.

And it works both ways. In school we get stories about how the MD missed the oral clues for classic textbook cases of disease (such as gluten enteropathy, amyloidosis) you forgot about since that path course years ago. Years later some dentist finally diagnosed it, because we are attuned to looking in the mouth everyday.

If you wanted to treat irreversible pulpitis that hurts like crazy, you would either need to do a root canal or extract the tooth. There is no medication that will fix the pulpitis.