Are Dutch dental students and dental-care providers competent prescribers of drugs?

Dental students and dental-care providers should be able to prescribe drugs safely and effectively. As it is unknown whether this is the case, we assessed and compared the prescribing competence of dental students and dental-care providers in the Netherlands. In 2017, all Dutch final-year dental students and a random sample of all qualified general dental practitioners and dental specialists (oral and maxillofacial surgeons and orthodontists) were invited to complete validated prescribing knowledge-assessment and skills-assessment instruments. The knowledge assessment comprised 40 multiple-choice questions covering important drug topics. The skills assessment comprised three common clinical case scenarios. For the knowledge assessment, the response rates were 26 (20%) dental students, 28 (8%) general dental practitioners, and 19 (19%) dental specialists, and for the skills assessment the response rates were 14 (11%) dental students, eight (2%) general dental practitioners, and eight (8%) dental specialists. Dental specialists had higher knowledge scores (78% correct answers) than either dental practitioners (69% correct answers) or dental students (69% correct answers). A substantial proportion of all three groups made inappropriate treatment choices (35%-49%) and prescribing errors (47%-70%). Although there were some differences, dental students and dental-care providers in the Netherlands lack prescribing competence, which is probably because of poor prescribing education during under- and postgraduate dental training. Educational interventions are urgently needed.

Predictors of oral cavity bleeding and clinical outcome after dental procedures in patients on vitamin K antagonists. A cohort study.

Patients on vitamin K antagonists (VKA) often undergo invasive dental procedures. International guidelines consider all dental procedures as low-risk procedures, while bleeding risk may differ between standard low-risk (e. g. extraction 1-3 elements) and extensive high-risk (e. g. extraction of >3 elements) procedures. Therefore current guidelines may need refinement. In this cohort study, we identified predictors of oral cavity bleeding (OCB) and evaluated clinical outcome after low-risk and high-risk dental procedures in patients on VKA. Perioperative management strategy, procedure risk, and 30-day outcomes were assessed for each procedure. We identified 1845 patients undergoing 2004 low-risk and 325 high-risk procedures between 2013 and 2015. OCB occurred after 67/2004 (3.3 %) low-risk and 21/325 (6.5 %) high-risk procedures (p=0.006). In low-risk procedures, VKA continuation with tranexamic acid mouthwash was associated with a lower OCB risk compared to continuation without mouthwash [OR=0.41, 95 %CI 0.23-0.73] or interruption with bridging [OR=0.49, 95 %CI 0.24-1.00], and a similar risk as interruption without bridging [OR=1.44, 95 %CI 0.62-3.64]. In high-risk procedures, VKA continuation was associated with an increased OCB risk compared to interruption [OR=3.08, 95 %CI 1.05-9.04]. Multivariate analyses revealed bridging, antiplatelet therapy, and a supratherapeutic or unobjectified INR before the procedure as strongest predictors of OCB. Non-oral cavity bleeding (NOCB) and thromboembolic event (TE) rates were 2.1 % and 0.2 %. Bridging therapy was associated with a two-fold increased risk of NOCB [OR=1.93, 95 %CI 1.03-3.60], but not with lower TE rates. In conclusion, predictors of OCB were mostly related to perioperative management and differed between low-risk and high-risk procedures. Perioperative management should be differentiated accordingly.

Management recommendations for invasive dental treatment in patients using oral antithrombotic medication, including novel oral anticoagulants.

OBJECTIVE: The aims were (1) to search the scientific literature from 2007 to 2012 for guidelines and new studies on the dental management of patients using oral antithrombotic medication; (2) to summarize the articles' evidence and recommendations; and (3) to propose an updated clinical practice guideline for general dentists. STUDY DESIGN: A systematic literature search in MEDLINE, Embase, and the Guideline websites, from October 2007 to October 2012, produced articles that were critically evaluated. RESULTS: The systematic literature search for guidelines yielded 74 citations (MEDLINE, 45; Embase, 22; and the Guideline websites, 7). Of these, only 2 guideline publications and 2 systematic reviews met the inclusion criteria. They yielded 32 recommendations. CONCLUSIONS: The evidence and subsequent recommendations from published guidelines all point in the same direction: do not interrupt oral antithrombotic medication, not even dual antiplatelet therapy, in simple dental procedures.

Review of postoperative bleeding risk in dental patients on antiplatelet therapy.

OBJECTIVE: We conducted a review of the literature to assess risk for oral bleeding complications after dental procedures in patients on antiplatelet therapy. STUDY DESIGN: We conducted a search in Medline, Embase, and National Guideline Clearinghouse databases for studies involving patients on single and dual antiplatelet therapy that had invasive dental procedures or manipulations that induce oral bleeding. RESULTS: The literature search yielded 15 studies that met inclusion criteria. There is a trend toward increased occurrence of immediate postoperative bleeding for dual antiplatelet therapy, but there is no increase in the occurrence of intra- or late postoperative bleeding complications. CONCLUSIONS: We found no clinically significant increased risk of postoperative bleeding complications from invasive dental procedures in patients on either single or dual antiplatelet therapy. These findings support the recommendation that there is no indication to alter or stop these drugs, and that local hemostatic measures are sufficient to control bleeding.

Treating dental patients who use oral antithrombotic medication: a survey of dentists in the Netherlands.

BACKGROUND: For many years, international guidelines have advised health care professionals not to adjust oral antithrombotic medication (OAM) regimens before invasive dental procedures. The authors conducted a study to examine the opinions of Dutch general dentists regarding the dental care of patients receiving treatment with these medications. METHODS: The authors invited via e-mail 1,442 general dentists in the Netherlands to answer a 20-item Internet-based questionnaire that they developed. Survey items consisted of questions about medical history taking, number of patients in the dental practice receiving OAM therapy, frequency of consulting with medical and dental colleagues and suggested dental treatment of patients during various invasive dental procedures. RESULTS: A total of 487 questionnaires were returned (response rate of 34 percent). The mean age of respondents was 47 years, and 77 percent were male. The majority of dentists responded that they obtain medical histories, but that they did not know how many of their patients were receiving OAM treatment. Dentists reported that they consult with medical colleagues frequently about antithrombotic medication. Ninety-one percent of respondents stated that they obtained their medical knowledge primarily in dental school. More than 50 percent of the dentists reported that they were not familiar with the international normalized ratio. The majority of dentists responded that they felt a need for clinical practice guidelines. CONCLUSIONS: According to the results of our survey, most dentists remain cautious when performing invasive dental procedures in patients who are treated with OAMs. Moreover, survey respondents tended to estimate that the risk of bleeding during dental procedures when OAM therapy is continued is higher than the risk of rethrombosis when use of antithrombotic medication is interrupted. CLINICAL IMPLICATIONS: A growing proportion of elderly patients and those with medically complex conditions are being treated in dental practices in the Netherlands. Consequently, more needs to be done to ensure that dentists are offered evidence-based guidance when treating patients who receive OAMs.

The influence of systemic diseases on the diagnosis of oral diseases: a problem-based approach.

Although all dentists are taught about the importance of oral health to general health and that systemic disease can manifest in the oral cavity, the 4-year dental school curriculum does not allow time to gain competency in these relationships. Nevertheless, all dentists must have skills in taking a medical history and an appreciation of oral findings that might have a systemic origin. This article focuses on the identification of abnormal signs and symptoms in the oral cavity and the determination of those that have a systemic origin. It is imperative that clinicians are mindful of the possible oral-systemic associations, because these could potentially have a huge impact on patient care.

Dental management of patients using antithrombotic drugs: critical appraisal of existing guidelines.

OBJECTIVES: The aims were: 1) to identify the guidelines available for management of dental invasive procedures in patients on antithrombotic drugs; 2) to assess their quality with the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument; and 3) to summarize their conclusions and recommendations. STUDY DESIGN: Systematic literature search for guidelines in several electronic databases. Retrieved guidelines were evaluated with the AGREE instrument for quality assessment. RESULTS: The systematic search yielded 93 results, of which only 4 were evidence-based practice guidelines. Two of these guidelines could be recommended for clinical use on the basis of the AGREE instrument. These 2 guidelines drew 68 conclusions from the existing literature and provided 58 recommendations. CONCLUSIONS: Two evidence-based clinical practice guidelines, satisfactorily fulfilling the criteria of the AGREE instrument and both published in 2007, advise to not routinely discontinue antiplatelet and anticoagulation medication before dental surgery. The majority of the recommendations, however, were not sufficiently linked to levels of evidence.

Dental enamel defects in children with coeliac disease.

OBJECTIVE: The aim of this study was to investigate whether Dutch children with proven coeliac disease show specific dental enamel defects, and to asses whether children with the same gastrointestinal complaints, but proved no-coeliac disease, lack these specific dental enamel defects. MATERIALS AND METHODS: Eighty-one children (53 coeliac patients and 28 control subjects) were examined during the period 2003-2004 in the Oral Surgery Outpatient Clinic of the Academic Medical Centre in Amsterdam. RESULT: Twenty-nine (55%) coeliac patients had enamel defects against 5 (18%) control subjects. In the coeliac disease group, the enamel defects were diagnosed as specific in 20 (38%) children, compared with 1 (4%) in the control group. Statistical analysis showed significantly more specific enamel defects in children with coeliac disease than in children in the control group (chi(2) = 12.62, d.f. = 2, P = 0.002). CONCLUSION: This study showed significantly more specific enamel defects in Dutch children with coeliac disease as compared with children in the control group. Dentists could play an important role in recognizing patients with coeliac disease.