Oral Surgeon DDS prescriptive authority

[viper2ko]

What can a DDS write for?

1. Amoxicillin
2. Tylenol #3
3. Dilaudid

1 and 2, or 1,2,3

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[Digsbe]

Any of them so long as it pertains to their scope of practice (oral healthcare).

 

[SterlingMaloryArcher]

An Oral Surgeon would be an MD/DDS

 

[Screwtape]

DDS here. Oral surgeons do 4 years of residency after dental school at minimum. Some do 2 years of medical school on top of the 4 year residency and are granted an MD. Right now the programs are about 50/50 MD/no-MD. However most practicing oral surgeons do not have an MD I believe.

Anywho, what pharmacist would think a dentist, let alone an oral surgeon, can't write for antibiotics or oral pain medication? I write for these virtually everyday, I understand it's your responsibility to verify prescribers are acting within scope but amoxicillin and Tylenol #3? Really lol, that would be a lot of calls to make. Dilaudid is over kill but every once in awhile the perfect storm of allergies and other medicine interactions forces my hand to write it.

 

[Rouelle]

They have full prescriptive authority for anything related to oral health/pain.

 

[Jibby321]

DDS here. Oral surgeons do 4 years of residency after dental school at minimum. Some do 2 years of medical school on top of the 4 year residency and are granted an MD. Right now the programs are about 50/50 MD/no-MD. However most practicing oral surgeons do not have an MD I believe.

Anywho, what pharmacist would think a dentist, let alone an oral surgeon, can't write for antibiotics or oral pain medication? I write for these virtually everyday, I understand it's your responsibility to verify prescribers are acting within scope but amoxicillin and Tylenol #3? Really lol, that would be a lot of calls to make. Dilaudid is over kill but every once in awhile the perfect storm of allergies and other medicine interactions forces my hand to write it.

My guess is that it's a practice question for this person's state pharmacy law exam.

 

[Rockinacoustic]

My guess is that it's a practice question for this person's state pharmacy law exam.

It sure smells like a k-type question...

 

[Screwtape]

My guess is that it's a practice question for this person's state pharmacy law exam.

Ah that makes more sense.

 

[CetiAlphaFive]

What can a DDS write for?
1. Amoxicillin
2. Tylenol #3
3. Dilaudid
1 and 2, or 1,2,3

I wouldn't do the Dilaudid for outpatient surgery from a DDS, MD, PHD, DO, esq., or literally anyone else unless there was a really, really, really good reason for it, and I had full access to the patients previous pain med regimen.

It sounds like a "yes man" oral surgeon providing concierge prescribing to a junkie.

 

[CetiAlphaFive]

Dilaudid is over kill but every once in awhile the perfect storm of allergies and other medicine interactions forces my hand to write it.

 

[ChalupaBatman86]

They have full prescriptive authority for anything related to oral health/pain.

I thought we settled this issue in a previous thread along with confirming they have so many herpes.


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[CetiAlphaFive]

I thought we settled this issue in a previous thread along with confirming they have so many herpes.
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New from Purdue!

ZYVOLAUDIDBUTEROL!!!

For the intrepid dentist that wants to treat their asthmatic addict patient's painfully lesion ridden netherparts.

 

[Rouelle]

I thought we settled this issue in a previous thread along with confirming they have so many herpes.


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Yep, it feels like we keep having the same discussions over and over. BTW, how's the job market in Seattle, San Francisco, and Manhattan? I heard CVS has a lot of metrics. Does retail really suck? Did anyone hear about that new pharmacy school?

 

[WVUPharm2007]

I'm more amazed by the amount of dentists that monitor the pharmacy forum for threads about them. Whenever these threads pop up every other month, there's always one right in here within minutes. I'm sort of impressed, honestly.

 

[CetiAlphaFive]

I'm more amazed by the amount of dentists that monitor the pharmacy forum for threads about them. Whenever these threads pop up every other month, there's always one right in here within minutes. I'm sort of impressed, honestly.

Yup. I don't think I've ever looked at the dds forum.

I'm glad they pop in though.

I can almost hear the conversation with a dds like screwtape on the phone.

"Uh huh... So the patient is allergic to tramadol, codeine, hydrocodone except for the yellow ones, oxycodone, methadone, oxymorphone, and all OTC pain meds?

Did you check PMP to see what they've been getting? Why not?"

I'm also interested in hearing them elaborate on the "medicine interactions" that would require someone to prescribe dilaudid.

 

[panicatthepharmacy]

Herpes meds only.

 

[Digsbe]

Yup. I don't think I've ever looked at the dds forum.

I'm glad they pop in though.

I can almost hear the conversation with a dds like screwtape on the phone.

"Uh huh... So the patient is allergic to tramadol, codeine, hydrocodone except for the yellow ones, oxycodone, methadone, oxymorphone, and all OTC pain meds?

Did you check PMP to see what they've been getting? Why not?"

I'm also interested in hearing them elaborate on the "medicine interactions" that would require someone to prescribe dilaudid.

I had a patient on zubsolv pill seeking and went to a dentist for "tooth pain that persisted for months" and the dentist gave them nearly a month's worth of hydromorphone because "allergic to codeine." When I called in regards to the zubsolv they asked "what's that" and I had to explain addiction treatment. When he finally asked "what pain med should I do?" I said "let's go with a non-opiate." He tried calling in Tramadol... We settled on ibuprofen 800. About 20% of my calls in regards to pain meds are due to suboxone/zubsolv/buprenorphine use that could have saved us both time had the PDMP been checked and the prescriber actually know what those meds are (for the record I'm not bashing dentists, I've had this convo with many providers).

 

[Screwtape]

Yup. I don't think I've ever looked at the dds forum.

I'm glad they pop in though.

I can almost hear the conversation with a dds like screwtape on the phone.

"Uh huh... So the patient is allergic to tramadol, codeine, hydrocodone except for the yellow ones, oxycodone, methadone, oxymorphone, and all OTC pain meds?

Did you check PMP to see what they've been getting? Why not?"

I'm also interested in hearing them elaborate on the "medicine interactions" that would require someone to prescribe dilaudid.

I do not know why you are being so condescending, but I will admit I am a young dentist and am happy to learn something new. The most recent patient i prescribed hydromorphone to was a patient of record who takes warfarin and the max chronic dose of acetaminophen for joint pain (or something). So i did a fairly invasive procedure where I removed a tooth and ground down bone. I wanted the patient to be comfortable so I wanted to give something stronger than tramadol. NSAIDs are out the window because of warfarin. Hydrocodone and tylenol #3 are out due to acetaminophen (I've heard there's a new hydrocodone product without tylenol in the states but I haven't heard dentists talking about it or using it, please enlighten me.) So I was left with oxycodone and hydromorphone and I believe they said they have had troubles with oxy (stomach upset, I know not a true allergy) in the past so I prescribed hydromorphone. Oxy would usually be my go to in this situation but patient said something about upset stomach with it. I gave three days worth. I am happy to get a pharmacists insight on this situation.

Edit. I originally said pt was allergic to codeine but I checked the record and this was incorrect. However if he were allergic to codeine I still would have prescribed the hydromorphone in this situation.

 

[zelman]

I do not know why you are being so condescending, but I will admit I am a young dentist and am happy to learn something new. The most recent patient i prescribed hydromorphone to was a patient of record who takes warfarin and the max chronic dose of acetaminophen for joint pain (or something). So i did a fairly invasive procedure where I removed a tooth and ground down bone. I wanted the patient to be comfortable so I wanted to give something stronger than tramadol. NSAIDs are out the window because of warfarin. Hydrocodone and tylenol #3 are out due to acetaminophen (I've heard there's a new hydrocodone product without tylenol in the states but I haven't heard dentists talking about it or using it, please enlighten me.) So I was left with oxycodone and hydromorphone and I believe they said they have had troubles with oxy (stomach upset, I know not a true allergy) in the past so I prescribed hydromorphone. Oxy would usually be my go to in this situation but patient said something about upset stomach with it. I gave three days worth. I am happy to get a pharmacists insight on this situation.

Edit. I originally said pt was allergic to codeine but I checked the record and this was incorrect. However if he were allergic to codeine I still would have prescribed the hydromorphone in this situation.

Zohydro is Hydrocodone ER, but most pharmacies won't stock it because it isn't abuse-deterrent.

Another correct solution to this situation was to tell the patient to take either two Tylenol every 6 hours or one Tylenol and one Norco.

 

[Rouelle]

I see no problem at all with hydromorphone. It's probably either that or morphine in this scenario. As long as it's not Demerol, I'm happy.

 

[Screwtape]

Zohydro is Hydrocodone ER, but most pharmacies won't stock it because it isn't abuse-deterrent.

Another correct solution to this situation was to tell the patient to take either two Tylenol every 6 hours or one Tylenol and one Norco.

Thank you for the information and that is a valid solution. For some of my already heavily-medicated elderly patients I like to keep my scripts simple but that would definitely work!

 

[SELDANE]

I do not know why you are being so condescending, but I will admit I am a young dentist and am happy to learn something new. The most recent patient i prescribed hydromorphone to was a patient of record who takes warfarin and the max chronic dose of acetaminophen for joint pain (or something). So i did a fairly invasive procedure where I removed a tooth and ground down bone. I wanted the patient to be comfortable so I wanted to give something stronger than tramadol. NSAIDs are out the window because of warfarin. Hydrocodone and tylenol #3 are out due to acetaminophen (I've heard there's a new hydrocodone product without tylenol in the states but I haven't heard dentists talking about it or using it, please enlighten me.) So I was left with oxycodone and hydromorphone and I believe they said they have had troubles with oxy (stomach upset, I know not a true allergy) in the past so I prescribed hydromorphone. Oxy would usually be my go to in this situation but patient said something about upset stomach with it. I gave three days worth. I am happy to get a pharmacists insight on this situation.

Edit. I originally said pt was allergic to codeine but I checked the record and this was incorrect. However if he were allergic to codeine I still would have prescribed the hydromorphone in this situation.

I think you logic is sound.

 

[Digsbe]

I worked at an outpatient pharmacy in a hospital that dispensed tons of hydromorphone because they performed bariatric surgery and hydromorphone 2mg was the smallest pill out there they could use for post op pain. I was personally fine with it. If it's for a valid reason and no reason to suspect abuse/misuse I don't see a major problem with it.

 

[CetiAlphaFive]

I do not know why you are being so condescending, but I will admit I am a young dentist and am happy to learn something new. The most recent patient i prescribed hydromorphone to was a patient of record who takes warfarin and the max chronic dose of acetaminophen for joint pain (or something). So i did a fairly invasive procedure where I removed a tooth and ground down bone. I wanted the patient to be comfortable so I wanted to give something stronger than tramadol. NSAIDs are out the window because of warfarin. Hydrocodone and tylenol #3 are out due to acetaminophen (I've heard there's a new hydrocodone product without tylenol in the states but I haven't heard dentists talking about it or using it, please enlighten me.) So I was left with oxycodone and hydromorphone and I believe they said they have had troubles with oxy (stomach upset, I know not a true allergy) in the past so I prescribed hydromorphone. Oxy would usually be my go to in this situation but patient said something about upset stomach with it. I gave three days worth. I am happy to get a pharmacists insight on this situation.

Edit. I originally said pt was allergic to codeine but I checked the record and this was incorrect. However if he were allergic to codeine I still would have prescribed the hydromorphone in this situation.

As others have pointed out, the opioid/APAP combo would eliminate the need for the OTC APAP, or they could be instructed to reduce their OTC apap in direct proportion to the combo apap.

In my opinion, 3 days of slightly exceeding the daily APAP limit

I think many professionals underestimate how many patients how many patients simply don't understand what a milligram is.
The vast majority believe that 1mg oxy = 1mg hydrocodone = 1mg = 1mg fentanyl.

Furthermore, this is compounded by the average patient's propensity to take 2 instead of 1, and then another 1 or 2 fifteen minutes later if the pain hasn't subsided.

Sorry, but prescribing an opioid naive patient something that is 2,800% more powerful than codeine just doesn't sit well with me.


Furthermore, in anyone other than a warfarin pt., high dose ibuprofen has been shown to be just as (more? Can't remember) effective than opioids, and it lacks the obvious and serious safety concerns.

Lastly, we're all aware of the recent studies showing that individuals prescribed opioids for acute pain are likely to continue opioids regardless of the resolution of pain from acute injury/procedure.
On a related note, the patient will probably develop the idea that only dilaudid works for them. That's pure speculation, so take it with a grain of salt.

 

[Screwtape]

As others have pointed out, the opioid/APAP combo would eliminate the need for the OTC APAP, or they could be instructed to reduce their OTC apap in direct proportion to the combo apap.

In my opinion, 3 days of slightly exceeding the daily APAP limit

I think many professionals underestimate how many patients how many patients simply don't understand what a milligram is.
The vast majority believe that 1mg oxy = 1mg hydrocodone = 1mg = 1mg fentanyl.

Furthermore, this is compounded by the average patient's propensity to take 2 instead of 1, and then another 1 or 2 fifteen minutes later if the pain hasn't subsided.

Sorry, but prescribing an opioid naive patient something that is 2,800% more powerful than codeine just doesn't sit well with me.


Furthermore, in anyone other than a warfarin pt., high dose ibuprofen has been shown to be just as (more? Can't remember) effective than opioids, and it lacks the obvious and serious safety concerns.

Lastly, we're all aware of the recent studies showing that individuals prescribed opioids for acute pain are likely to continue opioids regardless of the resolution of pain from acute injury/procedure.
On a related note, the patient will probably develop the idea that only dilaudid works for them. That's pure speculation, so take it with a grain of salt.

As I stated before, hydromorphone is far from my first choice in pain control. I am an avid supporter of the ibuprofen/APAP combo as it's shown to be the most effective with dental pain.

I am also aware of the opioid dependence issue but I have not seen any studies yet that show a three day course is likely to cause an opioid addiction.

I suppose we are just going to have to agree to disagree. It seems like 4/5 pharmacists (according to the posts above) agree with my logic. And if that's good enough for Colgate then that's good enough for me

 

[CetiAlphaFive]

As I stated before, hydromorphone is far from my first choice in pain control. I am an avid supporter of the ibuprofen/APAP combo as it's shown to be the most effective with dental pain.

I am also aware of the opioid dependence issue but I have not seen any studies yet that show a three day course is likely to cause an opioid addiction.

I suppose we are just going to have to agree to disagree. It seems like 4/5 pharmacists (according to the posts above) agree with my logic. And if that's good enough for Colgate then that's good enough for me

Are you joking, or did you really just accidentally reference the study that showed that a single 5 Day prescription greatly increases risk for chronic opioid use?

There's a reason our profession is in the toilet. Lol

 

[Screwtape]

Are you joking, or did you really just accidentally reference the study that showed that a single 5 Day prescription greatly increases risk for chronic opioid use?

There's a reason our profession is in the toilet. Lol

I'm not exactly sure what you mean but I'm aware of the study that states the spike in risk for dependence at the 5 day mark of a prescription. Which is exactly why I write for 3 days.

 

[Charcoales]

Seems fine. I def do not trust most patients to do calculus on maximum APAP dosing per day. As long as dilaudid dose is low then fine.

 

[CetiAlphaFive]

I'm not exactly sure what you mean but I'm aware of the study that states the spike in risk for dependence at the 5 day mark of a prescription. Which is exactly why I write for 3 days.

Yup. The study actually specified "less than three days", but that's commendable.

At this point I'm open to learning something me as well, so please disregard any semblance of snark in the following:

So, for the case you mentioned:

What did you recommend they do after the 3 days of their meds run out?
Surely the pain from the procedure remains after 3 days, and going from the 2nd most potent PO pain med to baseline would be a jump

 

[Screwtape]

Yup. The study actually specified "less than three days", but that's commendable.

At this point I'm open to learning something me as well, so please disregard any semblance of snark in the following:

So, for the case you mentioned:

What did you recommend they do after the 3 days of their meds run out?
Surely the pain from the procedure remains after 3 days, and going from the 2nd most potent PO pain med to baseline would be a jump

Three days should definitely get them over the pain hump. And the APAP they are already taking should get them the rest of the way. I don't tell patients I am going to control 100% of their pain. I tell them they are probably going to be a little sore for the next week or so. They understand that. And I also use the same old spiel of "I'd rather them have it and not need it than need it and not have it" every time I give opioids. If they don't need it then don't take it. No real complaints yet.

 

[TanMan]

I thought we settled this issue in a previous thread along with confirming they have so many herpes.


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Haha, that statement makes it seem like we all have herpes or something. Although we may have the highest incidence of workplace related non-sexually transmitted herpes.

I'm more amazed by the amount of dentists that monitor the pharmacy forum for threads about them. Whenever these threads pop up every other month, there's always one right in here within minutes. I'm sort of impressed, honestly.

The pharmacy forums are way more interesting than the dental forums. I enjoy reading the dedication that a lot of pharmacists have for their profession despite the hardships and corporate takeover that seems to be going on these days. Considering that I have a few friends who are pharmacists, its interesting to know what they are going through when they b!tch and moan about the hardships that's going through their careers.

Although, as a dentist, I wouldn't feel comfortable giving hydromorphone or oxycodone (never have, never will, because it was never part of my training). Most I'll give is 10 tabs of hydrocodone/apap (or vicoprofen - no refills) if I had to drill their alveolar bone, infection/swelling of the fascial spaces, severe periapical perio accompanying a root canal and they had a previously bad reaction to tramadol.

If the oral surgeon did something like a lefort surgery or BSSO, I would think they are within the scope of prescribing hydromorphone. For a surgical extraction (sectioning roots, removal of bone, etc...), I think it might be a bit much, especially if you are going to combine it with antibiotics and a steroid.

What are your thoughts (as a pharmacist) with regards to dentists prescribing hydrocodone/apap and opioid addiction? I haven't had a pharmacist contact me about my prescriptions, but you guys may have different thoughts or feeling with respect to what dentists prescribe and for what reason.

 

[ChalupaBatman86]

Haha, that statement makes it seem like we all have herpes or something. Although we may have the highest incidence of workplace related non-sexually transmitted herpes..

I am going to guess you guys have ALL the workplace non-sexual herpes although politicians probably try to claim them twice as often.



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[TanMan]

I am going to guess you guys have ALL the workplace non-sexual herpes although politicians probably try to claim them twice as often.



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LOL, back then, dentistry was performed without gloves. I can only imagine the incidence of herpetic whitlow and the aerosolization of saliva through air driven instruments and procedures.

 

[zelman]

What are your thoughts (as a pharmacist) with regards to dentists prescribing hydrocodone/apap and opioid addiction? I haven't had a pharmacist contact me about my prescriptions, but you guys may have different thoughts or feeling with respect to what dentists prescribe and for what reason.

I know heroin addicts with a bunch of fillings they didn't need because they knew if they told their dentist a tooth hurt enough times they would get Vicodin. You guys may not cause a ton of addictions, but you're seen by addicts as an easy way to score opiates.

 

[CetiAlphaFive]

I know heroin addicts with a bunch of fillings they didn't need because they knew if they told their dentist a tooth hurt enough times they would get Vicodin. You guys may not cause a ton of addictions, but you're seen by addicts as an easy way to score opiates.

Yup.
I'd say dentists are very good about limiting quantities.

I don't know anything about their security, but I'd say about 1 dentist per year gets a script pad stolen in Austin/ central Texas. At least every other year.

 

[TanMan]

I know heroin addicts with a bunch of fillings they didn't need because they knew if they told their dentist a tooth hurt enough times they would get Vicodin. You guys may not cause a ton of addictions, but you're seen by addicts as an easy way to score opiates.

I'd think that going to the dentist is a hardly an easy way to score opiates (at least from an ethical, conscientious dentist standpoint). Seems like a lot of trouble to score opiates (have a legitimately diagnosed condition that would require a procedure that would then result in prescribing pain medications in limited quantity depending on severity of condition, invasiveness of procedure, and medical history). The oral cavity is an interconnected system and if the patient has pain that we cannot diagnose as dental, then we have no business prescribing any kind of pain medication because that does not fall within our scope of practice (refer to MD or MD specialty as needed). I sure as hell wouldn't prescribe opiates for fillings, but if they come with a legitimate condition and I expect pretty severe post-op pain, I don't think that it is unethical to prescribe limited quantities of pain medication.

At least from our training, we have a battery of tests to determine if it is of dental or non-dental origin. These tests are not exactly the best tests to be subjected to, but perhaps they are desperate enough to score even a few tabs. People are typically unaware of the positions of their teeth, so the subjective portion of the examination is important to determine whether they are faking pain, or it is real pain. Reading their body language and correlating it with their verbal responses is important as well. Then again, you guys are in the front lines, so you would be able to identify addicts and their respective behaviors a lot better.

I would ask this question, would an addict subject themselves to painful and expensive procedures (root canals or extractions) to score a few tabs of opiates?

 

[Old Timer]

What can a DDS write for?

1. Amoxicillin
2. Tylenol #3
3. Dilaudid

1 and 2, or 1,2,3

The answer is all three. Anybody who says otherwise is wrong. Whether the pharmacist should fill it is another issue all together. It is legal to write it, period.

 

[TanMan]

The answer is all three. Anybody who says otherwise is wrong. Whether the pharmacist should fill it is another issue all together. It is legal to write it, period.

Never did answer the original post's question. As dentists, I think we have the prescribing authority for Schedule 2/2N and below.

 

[zelman]

People are typically unaware of the positions of their teeth, so the subjective portion of the examination is important to determine whether they are faking pain, or it is real pain. Reading their body language and correlating it with their verbal responses is important as well. Then again, you guys are in the front lines, so you would be able to identify addicts and their respective behaviors a lot better.

Opiate withdrawal symptoms often make identifying pain difficult since they are in genuine discomfort.

I would ask this question, would an addict subject themselves to painful and expensive procedures (root canals or extractions) to score a few tabs of opiates?

Well, people without cash prostitute themselves for drugs, so yes.

 

[WVUPharm2007]

Some dude writes a K type question for a board exam he's studying for and it turns into this nonsense. Never change, SDN.

 

[theleatherwalle]

Wife is a pharm.D. and I'm a D.M.D. As a general dentist, I would never write for fentanyl. I can see no reason why an oral surgeon would write for fentanyl either. You're just inviting the DEA into your life.

 

[Screwtape]

Wife is a pharm.D. and I'm a D.M.D. As a general dentist, I would never write for fentanyl. I can see no reason why an oral surgeon would write for fentanyl either. You're just inviting the DEA into your life.

Who said anything about fentanyl? lol

 

[CetiAlphaFive]

Who said anything about fentanyl? lol

The comparison is apt. Look at their receptor affinities.

 

[confettiflyer]

I enjoy reading the DDS/DMD folks' posts when they visit, welcome to ****show pharmacy. I had many close dental school student friends that would invite me over for dinner back in the day.

I also don't see an issue with short course Dilaudid, but I'm an inpatient creature with different considerations than my outpatient brethren.


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[CetiAlphaFive]

I enjoy reading the DDS/DMD folks' posts when they visit, welcome to ****show pharmacy. I had many close dental school student friends that would invite me over for dinner back in the day.

I also don't see an issue with short course Dilaudid, but I'm an inpatient creature with different considerations than my outpatient brethren.
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Spend a day with us in the hellish community wastelands.

An actual (paraphrased) quote from when I was at Target:

"Hello, did the doctor call the refill on my husband's blood pressure medicine?"
"We're still waiting ma'am."
"Well my husband's valsartan is 80mg do I just gave him 4 of my lisinoprils to match the dose"

 

[radio frequency]

An actual (paraphrased) quote from when I was at Target:

"Hello, did the doctor call the refill on my husband's blood pressure medicine?"
"We're still waiting ma'am."
"Well my husband's valsartan is 80mg do I just gave him 4 of my lisinoprils to match the dose"

This quote absolutely does not surprise me in any way.

 

[CetiAlphaFive]

This quote absolutely does not surprise me in any way.

Yup.

It would not surprise me in the least if a patient took five 2mg hydromorphone tags to equal their usual norco.


It would also not surprise me if they accidentally took 40mg of karatecodone.

 

[confettiflyer]

"Hello, did the doctor call the refill on my husband's blood pressure medicine?"
"We're still waiting ma'am."
"Well my husband's valsartan is 80mg do I just gave him 4 of my lisinoprils to match the dose"

I'm imagining this old guy in a walker having a syncopal episode while reading a Garfield birthday card in the greeting card aisle at Target.