Table of Contents

Inside Dentistry

September 2006, Volume 2, Issue 7
Published by AEGIS Communications

Bugs, Drugs, Pain and Anxiety: Considerations for Proper Prescriptions in Today’s Dental Practice

Allison M. DiMatteo, BA, MPS

Over the past 15 years, the US Food and Drug Administration (FDA) has approved a variety of pharmaceuticals for the treatment of everything from pain to acid reflux, depression to high cholesterol, arthritis to toenail fungus, and just about everything in between. The challenge in today’s dental practice environment is examining the available pharmaco-therapeutics and drawing conclusions about their direct and indirect dental applications and implications.

“There are about 20 to 30 new medications introduced each year, and many dental patients will be given these drugs by their physicians when they’re eventually approved,” explains Richard Wynn, BSPharm, MS, PhD, a professor of pharmacology at the University of Maryland Dental School and a regular contributor of a column about dental pharmacology in the Academy of General Dentistry journal. “More patients are living longer and taking more medications, so dentists should be concerned today about how the pain relievers, anesthesia, or other drugs they use for dental treatments will react with these new medical prescriptions.”

Dentists are mandated to prescribe medications only for those conditions and diseases within the scope of their practice, explains Morton Rosenberg, DMD, a professor of oral and maxillofacial surgery at Tufts University School of Dental Medicine. So, prescribing medications for a disease like hypertension is outside the purview of their dental license. But, dental practitioners can prescribe any drugs that have applications to dentistry, he says.

In today’s dental practice world, the prescribing habits associated with those applicable drugs have been affected in a sense by the new medications that are available, observes D. Walter Cohen, DDS, Chancellor Emeritus of Drexel University College of Medicine and Dean Emeritus of the University of Pennsylvania School of Dental Medicine. Dentists are writing more prescriptions than they did in the past based on the choices available.

And there are plenty of them. There are more than 800 generic and 2,500 brand-name drugs used in dentistry and medicine combined, as outlined in the ADA Guide to Dental Therapeutics (www.ada.org/prof/resources/pubs).

“To the benefit of patients today, there are a lot of medications coming out that are much more receptor/site specific,” explains Ronald Kulinksi, DDS, BS Pharm, the director of dental medicine with Moses Cone Health System in Greensboro, North Carolina, and a former Registered Pharmacist. “So, hopefully more drugs today are given for specific indications/ actions and with the desired results, not with all the major side effects.”

Paul Moore, DMD, PhD, MPH, a professor of pharmacology and the chair of the department of dental anesthesiology at the University of Pittsburgh School of Dental Medicine, notes that 15 years ago, one of the commonly used antibiotics was erythromycin, which could affect the metabolism of other drugs. Today, hardly any dental practitioners will prescribe erythromycin because there are newer antibiotics available (eg, azithromycin) that won’t create problems with drug interactions, Moore says.

“Sometimes we look at new prescribing habits because there are new agents on the market (eg, local anesthetics, new analgesics),” Moore explains. “Other times we look at new agents on the market because they provide some benefit or, because dentists are essentially risk aversive, we move to alternative agents that present less risk to the patient.”

However, some in the pharmaceutical industry see very little use of drugs by dentists in general. Therefore, given the fact that dentists may not be routinely prescribing some of the newer pharmaceuticals available, there is a need to educate practitioners on the benefits of using package inserts as a source of valuable information, explains Michael Cavanaugh, the executive director of marketing at OraPharma. This information can be of significant importance to both the dentist and the patient, he says, especially when a new medication is being used.

Given the greater potential for drug interactions that dentists must consider today, how they go about prescribing for pain, anxiety, and infection may very well determine just what kind of care they’re providing their patients. Here’s the Inside look at how prescribing habits have changed in recent years in response to improved pharmaceuticals and how you can enhance your likelihood of prescribing properly when treating polypharmacy patients.

Changes in Practitioners’ Pickings

Among those medications that had a major impact on dentistry in recent years were the selective COX-2 inhibitors, which were quite the rage several years ago for relieving pain. They were more popular than older drugs because they were thought to deliver predictable efficacy while minimizing gastrointestinal side effects. However, after becoming so widely used, it was ultimately recognized that they had the potential for causing cardiovascular problems, notes Raymond Dionne, DDS, PhD, scientific director of the division of intramural research for the National Institute of Nursing Research (NINR).

“After a period of controversy and hearings by the FDA, most of them were withdrawn from the market,” Dionne says.

From the standpoint of pain relief, for decades dentistry used drugs that were a combination of a narcotic and aspirin or acetaminophen, Dionne says. With the advent of nonsteroidal anti-inflammatory drugs (NSAIDs) in the 1970s and 1980s, most health care providers eventually switched to those newer analgesics as their primary pain-relieving agents. To relieve the apprehension reported by many patients, midazolam replaced diazepam for sedative use, and propofol—which is actually an injectable general anesthetic—became more widely used in dental practices. Today, however, various oral drugs that have faster onset and that are sometimes administered sublingually have replaced—somewhat—the use of older sedative drugs that were given in high doses to sedate anxious patients, Dionne notes.

The willingness by practitioners to explore the applications to dentistry of new pain and anti-anxiety medications is based on the fact that all patients have an expectation that they are going to be relatively pain-free when they are undergoing a dental procedure and when they leave the dental office, Dionne explains. It’s not an unreasonable expectation; if patients had to undergo most dental procedures without local anesthetic or postoperative pain medications, it would be a fairly miserable experience. In years past, pain and the fear of it produced apprehension about going to the dentist, he says.

“Surveys have shown that the amount of patients in the population who indicate that they are very fearful or phobic about going to the dentist has stayed about 15% for about the last 15 to 20 years,” Dionne outlines. “It doesn’t look like it’s decreasing, despite the fact that with all of the preventive techniques we have, you would think that people would be less likely to have bad memories.”

Therefore, dental practitioners need drugs that will be effective local anesthetics so that patients won’t feel pain during a procedure. Fortunately, most of what’s available is effective, although they are aversive to patients because they require intraoral injections. So, something is usually administered to the patient either before surgery or before the local anesthetic wears off that will block or inhibit the development of postoperative pain.

Moore and his colleagues recently analyzed prescribing data received from randomly surveyed practicing oral surgeons and found that for third molar extractions, 46% of the 563 respondents used general anesthesia; 33% used intravenous conscious sedation; 6% used nitrous oxide sedation; 2% used oral sedation; and 13% used local anesthesia alone.1 For intravenous conscious sedation, a three-drug technique using midazolam, fentanyl, and propofol was reported most commonly. The most frequently selected local anesthetic formulations were 2% lidocaine, 1:100,000 epinephrine for surgical anesthesia, and 0.5% bupivacaine/ 1:200,000 epinephrine for postoperative pain management.1

These authors also examined prescribing practices for peripherally acting and centrally acting analgesics, corticosteroids, and antibiotics after third molar extraction.2 The most frequently used peripherally acting analgesic (as reported by 74% of respondents) was ibuprofen, with the most frequently prescribed doses being 800 mg, 600 mg, and 400 mg. The centrally acting analgesic prescribed most frequently was the combination of hydrocodone with acetaminophen, as reported by 64% of the respondents.2 Moore and his colleagues found that the frequency with which antibiotics and corticosteroids were administered varied widely based on perceived patient need and dentist expectations.2

Another pharmaceutical development that has seen increased use in dentistry is site-specific antibiotics and antimicrobials, particularly for treatments in the periodontal arena, explains Kulinski. He notes that having a medication that can be placed into the periodontal pocket to provide antibiotic or antimicrobial therapy really helps keep the treatment localized and site-specific. There is less potential for systemic interaction and systemic side effects, and clinicians should observe a better response because the medication doesn’t have to travel through the bloodstream to perform its intended action.

“With local delivery systems, we are able to administer relatively high concentrations of drugs to the specific site where we want them to act,” Moore elaborates. “I think that is something we will see more and more of in the future.”

Along these lines, whereas it was once thought that a host of bacteria caused periodontal disease, various research methodologies have identified four or five specific bacteria that effect and/or cause periodontal problems, Kulinski says. As a result, clinicians now are more specifically prescribing medications that actually target those specific bacteria.

“Our impression from talking to different dental offices—including periodontal practices—is that there are more prescriptions being written especially for site-specific antibiotic therapy,” observes Margaret Scarlett, DMD, president of Scarlett Consulting International. “Developing regimens that are part of the overall medical management of periodontal disease is a growing area that’s based on best practices and best evidence.”

However, whether in terms of antibiotics or anesthetics, Wynn says there really haven’t been any new cutting-edge developments in these areas. If he had to define what a cutting-edge dental pharmacology development would be, he says an anti-caries vaccine would fall into this category; it’s something that would change the practice and scope of dentistry.

“Kids would get a vaccine early on instead of fluoride,” Wynn postulates. “Then, they wouldn’t need fluoride because they would never get cavities.”

Considering Best Practices

In some dental offices and for some treatments, drug therapy is considered to be the best practice. The gold standard of practice, Cavanaugh says, is derived or created by insurers based on what they’re willing to pay and for what, as well as how frequently.

Whereas in medicine there is a standard for the treatment and management of diabetes, for example, such a standard does not exist for the treatment of periodontal disease. Cavanaugh’s example is one in which a patient might visit one dental office and not be probed, or walk into another office and be probed and receive scaling and root planing. One dental office might treat a specific condition with systemic antibiotics, while another will use local antibiotics; a third will use a rinse, he suggests.

According to Wynn, drugs are not insignificant, but a somewhat minor part of the entire scope of the dental practice spectrum. The new drug therapies presented to clinicians today are merely variations of existing treatments.

Using periodontal treatments as the example, Wynn explains that the use of a systemic antibiotic has been used for years to rid the gums of the bacteria causing the disease. The new variation on that was the development of an agent carrying the antibiotic that could be applied directly into the gums themselves—a local application of a systemic antibiotic, Wynn clarifies.

In some offices, Cohen says it’s common practice to send bacterial plaque samples to a laboratory so that the specific pathogens causing the periodontal infection can be identified. The laboratory not only identifies the specific pathogen, but also information about which specific drugs the particular bacteria are sensitive to, which helps in prescribing, he says.

“So, I think the general practitioner needs to know what the specific pathogens are—the bacterial contents of plaque—that are causing the problem,” Cohen emphasizes.

In terms of relieving pain, today’s medications have a wide margin of safety when clinicians use them in the correct manner, Dionne says. Administering anxiety relief medications may be trickier because the most effective means for relieving anxiety—such as general anesthesia or deep sedation—have a fair amount of risk associated with them, even in a hospital under ideal circumstances, he notes.

Therefore, dentistry has developed alternatives such as parenteral premedication that are effective and safe but do require higher levels of training, Dionne says. Currently, controversy exists regarding whether people who have taken high doses of drugs orally or sublingually—under the assumption that the oral route is safer and, therefore, you can administer higher doses—experience better efficacy without the risks associated with IV administration. He notes that there is a fallacy in this thinking because once a drug reaches a high blood level, it doesn’t matter how it got there—its risks are the same.

According to Dionne, members of the dental profession are currently reacting to controversies surrounding oral premedication by developing guidelines that represent the judicious use of sedative drugs. Additionally, those guidelines involve what training should be required for its use, as well as what emergency procedures dentists should be prepared to perform and how to best monitor patients during dental treatments.

Mixing & Matching Medications

The potential of today’s pharmaceuticals runs in two directions, cautions Cohen. The systemic benefits they provide may be long-awaited pearls for patients. However, certain drugs being prescribed today can cause a host of problems in the oral environment.

For example, transplant patients who receive an immunosuppressant drug may experience enlarged gums. Patients with cardiovascular disease who are taking a calcium channel blocker also may experience an overgrowth of gum tissue, Cohen points out. Or, consider that spontaneous and other potential problems have been associated with the bisphosphonates used to treat osteoporosis and/or some types of cancer, including multiple myeloma, notes Kulinski.

“Dentists must be aware of not only what they’ve prescribed, but also what the patient is already taking,” Cohen explains. “Dentists have to know how what they’re going to prescribe is used and how the other drugs a patient is taking may impact the oral cavity.”

So, whether you’re prescribing to alleviate pain, infection, or anxiety, remember that standard medical history-taking remains of paramount importance to patient safety. In fact, Kulinski says that an evaluation of current medications and those that were taken in the past should be assessed on an appointment-by-appointment basis.

“My first question to patients when obtaining vital signs at every visit is about any recent changes in medications or any allergic reactions,” Kulinski says. “I may have treated the patient 1 week before, but he or she could have had a reaction to something or a new medication could have been added or taken away that will lead me to prescribe something different.”

Rosenberg asserts that it’s important for dentists to know and understand the adverse effects of any drugs they’ll be using or prescribing; what their side effects are; and what their possible interactions may be with other drugs that either the patient is taking or the dentist may be using. When taking a patient’s medication history, Rosenberg suggests detailing the nonregulated herbal supplements that patients may be taking and may think are “okay.” In fact, he says, these can also have considerations for clinical dentistry, such as antihemostatic properties or lowering blood pressure.

“Medication history has become very important especially with older patients who are on many different medications,” explains Cohen. “These different drugs can affect the oral cavity in many ways. Some drugs cause less salivary flow, while others can actually affect the gingival tissue and cause changes.”

In fact, Moore notes that there have recently been concerns regarding the effects of patient medications on salivary flow and oral lesions. Therefore, clinicians need to be aware of patients’ prescription history in order to determine if it has contributed to any oral manifestations that are observed. It may also have relevancy to the manner in which dental professionals will manage caries and/or periodontal disease, he says.

Other Prescribing Pointers

Cohen asserts that before prescribing anything, it’s important to know if the patient is experiencing discomfort and, if so, what type of pain it is and how long they’ve been experiencing it. Then, what’s causing the pain should be identified so that the most appropriate treatment and medication can be planned/prescribed to relive the pain.

“Dentists also need to know if there is an infection,” Cohen says. “If the patient needs an antibiotic, what’s prescribed will vary depending on what the infection is.”

However, regarding the prescription of antibiotics, there is growing concern about overprescribing by dentists and other providers to the extent that the Centers for Disease Control and Prevention launched a campaign to reduce the unnecessary use of antibiotics by health care providers.3 Originally launched in 1995 as the “National Campaign for Appropriate Antibiotic Use in the Community,” it was renamed “Get Smart: Know When Antibiotics Work” in 2003 in conjunction with the launch of a national media campaign to reduce the rate of increasing antibiotic resistance.3

The ADA recognizes the significance of antibiotic resistance and, earlier this year, listed the need to study the use of antibiotics and the development of antibiotic resistance among its issues important to dentistry.4 Further, the ADA mission statement found it important to promote the development of guidelines for using antibiotics in dentistry, as well as identifying appropriate and inappropriate drug regimens and indications for antibiotic prophylaxis.4

“There is a growing need for an evidence-based review of guidelines for prescribing antibiotics because of both potential benefits and resistance concerns based on current prescription patterns of dentists,” explains Scarlett. “Dentists need to use antibiotics judiciously, when necessary, as well as review compliance issues with their patients to avoid resistance, where possible.”

To that end, clinicians should monitor patient compliance with pharmaceuticals that have been prescribed for them and specifically ask them if they have taken all of their medication. According to Cavanaugh, patient compliance in terms of how prescription medications are used and refilled is a serious issue that affects dentistry just as much as traditional medicine. Contributing to the lack of compliance is the fact that most problems in dentistry are acute; it’s not “the norm” to emphasize the need for persistent use of a medication for a dental problem.

“When analyzing prescription data for drugs that are indicated for long-term use in dentistry, we see a lot of new prescriptions being written, but we don’t see a lot of refills being written,” he says. “That tells you that the patient isn’t taking the product as indicated and that dentists are faced with the same challenges as their medical counterparts: driving home the need for compliance with their patients.”

Additionally, dentists must recognize that some of the drugs being introduced have real implications or considerations for the dental appointment, Rosenberg cautions. Clinicians therefore need to understand the pharmacological basis of the therapeutics that they’re about to prescribe and/or use.

Consider that the medical emergency that may occur in the dental office could result from an interaction between medications the patient is already taking and those administered by the dentist, or from a pre-existing condition. For this reason, Wynn says that dentists must be up-to-date on how to handle potential emergencies, as well as what interactions could potentially become life-threatening.

“For example, a certain number of drugs (eg, antibiotics, antidepressants) will affect the heart—specifically the QT interval—even though they’re not associated with or prescribed for heart problems,” explains Wynn. “If dental patients are taking one of these medications, they could have an increased risk of having a cardiac arrhythmia; anxiety can precipitate that cardiac arrhythmia in patients taking these types of medications.”

Conclusion

Our experts agree that the most important thing a general dental practitioner can do within this changing pharmaceutical environment—one in which a new drug is introduced almost daily—is to keep up-to-date with what’s happening in the field. Attend review courses, read package inserts to see what the drugs do and how they could affect dental appointments, and maintain a pharmacological knowledge base so that you can make your own personal, intelligent evaluations of new drugs as they’re introduced. Maintaining active pharmacology and dental therapeutic training will enable clinicians to use medications properly in their practices as they become available. Most importantly, doing so will help to ensure that their patients receive the safest state-of-the-art treatment of infections, pain, and anxiety in the dental office.

1 Moore PA, Nahouraii HS, Zovko JG, et al. Dental therapeutic practice patterns in the U.S. I. Anesthesia and sedation. General Dentistry. March-April 2006;54(2):92-98.

2 Moore PA, Nahouraii HS, Zovko JG, et al. Dental therapeutic practice patterns in the U.S. II. Analgesics, corticosteroids, and antibiotics. General Dentistry. March-April 2006;54(2): 201-207.

3 Centers for Disease Control and Prevention.Available at: www.cdc.gov/drugresistance.

4 Research of Importance to the Practicing Dentist, 2005-2006. Mission Statement. American Dental Association. January 2006.Available at:www.ada.org.

SIDEBAR 1

Dentistry and the Prescription Sales Pitch
When changes in prescribing habits are seen, Michael Cavanaugh from OraPharma attributes them in part to live representative detailing through which an entire dental office staff can be educated. “It’s important that the entire staff understands new medications, and representative detailing is what we see having more of an effect on prescribing habits,” he says.

Dental pharmaceutical detailing does differ from that conducted throughout the medical field. Cavanaugh explains that there aren’t many high-margin pharmaceutical products used for the mouth, and the level of detailing required has typically not been very complicated. That’s changing somewhat, he says, but not significantly.

According to Richard Wynn, BSPharm, MS, PhD, from the manufacturers’ standpoint, dentistry is a small market compared to the medical field. It’s not worth the financial investment to send detailing representatives to dental offices. When they are present, drug-company representatives are not as intense in the dental environment as they are in the medical environment, with fewer calls being made to dental offices, says Morton Rosenberg, DMD.

However, the fact that the dental market has always been considered so much smaller than the medical marketplace is not necessarily a bad thing, believes Raymond Dionne, DDS, PhD. Detailmen are salesmen promoting their product. Very often it’s a product new to the market that may or may not be better than an existing drug but that costs much more because it’s a trade brand, he says. If you can treat a patient with a generic drug, then you can achieve the same therapeutic outcome and possibly have fewer risks associated with it, Dionne explains. With new drugs, it always takes time before any particular problems are detected (eg, selective COX-2 inhibitors).

Based on feedback from assorted market research initiatives, our experts suggest that general dental practitioners also keep up with changes in the area of pharmaceuticals via local and national continuing education programs, journal articles, and their local study clubs. Either way, keeping abreast of the introduction of new approved medications, as well as maintaining an updated awareness of what medications patients are taking, can help alert dental practitioners to potential drug interactions, side effects, and possible effects on the oral cavity, says D. Walter Cohen, DDS.

Interestingly, as important as receiving credible information about pharmaceuticals with applications and implications for dentistry is providing it. Paul Moore, DMD, PhD, MPH, from the University of Pittsburgh School of Dental Medicine, says that it’s important for dental practitioners to take the time to report adverse events that may be associated with drugs to the manufacturer and to the Food and Drug Administration’s MedWatch (www.fda.gov/medwatch).

“When dentists see adverse effects or something unusual in a patient that is taking a specific medication, there are mechanisms to report rare but significant problems,” Moore emphasizes. “What happened with bisphosphonates is a recent example of how important it is when a drug is first introduced on the market that practitioners take the time to report instances of adverse effects seen with the medication.”

Wynn says the annual meeting of the American Dental Association (ADA) offers a tremendous number of courses dealing with dental pharmacology that are free with the price of conference registration. Also, the Academy of General Dentistry (AGD) annual July meeting provides contemporary pharmacology information to dentists. Finally, speakers—including Wynn himself—travel the country to discuss new drugs and dental products that have recently been approved.

When obtaining information about new pharmaceuticals from journal articles, Dionne cautions that some literature may be inadequate for informing dental professionals about what the latest treatments are, or about the level of evidence that’s associated with the effectiveness and safety of a particular treatment. What’s more, according to Ronald Kulinski, DDS, BS Pharm, no matter how many clinical trials are conducted, drug manufacturers will never reach all of the patients who could have potential adverse side effects, some of which might not be identified until a medication has been on the market for some time.

“An instructor back in dental school used to say, ‘Don’t be the first person or the last person to start using a new drug,’ the idea being that if you are on the leading edge, you run the risk of unexpected toxicity,” remembers Dionne. “Conversely, once a drug has been around for awhile and has been recognized to be safe and effective, then you’re denying its benefits to your patients if you refuse to change with the times.”

SIDEBAR 2

E-scribing: How Electronic Prescriptions Might Help You & Your Patients
Electronic communication has infiltrated just about every aspect of modern life, and medicine and dentistry are no exception. However, when it comes to prescriptions, what’s permissible, what’s not, and where is subject to state-by-state regulations.

According to the 2006 National Association of Boards of Pharmacy Survey of Pharmacy Law (Table) , 44 states appear to allow prescription transmission from an in-state prescriber computer to a pharmacy computer; three states—in addition to the District of Columbia—do not allow it and three states—in addition to Puerto Rico—haven’t addressed the issue either way. Some states allow electronic prescriptions to be transmitted between an out-of-state prescriber computer to a pharmacy computer, while others do not. Or, some states allow electronic prescription transfer between in-state pharmacy computers only.

What’s meant by “appear” is that the states that supposedly allow electronic prescriptions have established some form of regulator framework for them, explains Margaret Scarlett, DMD, president of Scarlett Consulting International. Some states think of electronic prescribing as transmission from provider computer to pharmacy computer, and others consider electronic prescriptions as transmission of a fax from provider to fax of the pharmacy.

“The requirements vary because the states vary, and it’s somewhat confusing,” Scarlett says. “There is just not a national standard on this, and there is a growing need to have one.”

Dental practitioners working in a state that does allow electronic prescriptions can take advantage of its efficiency and safety benefits by first acquiring the software necessary to write the electronic prescription. Once it’s been properly installed, clinicians should set up their “safe signature” and establish a system for transmittal of the prescriptions from their computers to the pharmacy computers; this involves ensuring that the pharmacies you’ll be sending prescriptions to are set up to receive them.

Scarlett notes that even if the pharmacy isn’t prepared to receive an electronic prescription, dentists can still generate one that has an electronic signature on it and simply print it out, giving the paper copy to the patient. It still takes less time, she says. Also, if the prescription program is mostly menu-driven and tied to other patient information (eg, other medications the patient is taking), potential adverse interactions and/or contraindications will be automatically identified.

“In terms of patient safety, there is tremendous incentive to go to electronic prescriptions,” Scarlett explains. “For example, if you try to write a prescription for amoxicillin for a patient whose medical record says they’re allergic to it, the system won’t let you write it and will alert you to a problem.”

Although not necessarily combined or related to electronic prescriptions, Ronald Kulinski, DDS, BS Pharm, says that some of the various clinical reference library materials that are available online or via downloadable software can help dental practitioners keep track of all of the medications their patients are taking. If something needs to be prescribed, it can be run through the drug interaction modality of the software to see if any potential problems may arise.

Reference databases and information technology systems may be helpful in understanding current medications and prescriptions, in addition to avoiding drug interactions, in today’s and tomorrow’s dental practice, Scarlett notes. However, while this method may reduce errors and increase patient safety, the need for good controls to avoid fraud or misuse will grow, and computer safety will be important, she says.

With more people living longer—yet possibly with chronic diseases and disabilities—and taking more medications, the oral-systemic linkages of their drug regimens may change over time. Using electronic patient records and prescriptions can help track these changes and facilitate customized and individualized dental treatment plans.

As the individual states continue to set standards and develop rules for electronic prescriptions, it’s only a matter of time, Scarlett says, before they’re as much a part of the dental office as electronic treatment planning, payment submission, and electronic receipts. It’s where the profession needs to go in order to move forward in the true medical management of oral disease, not just caries and periodontal disease, she believes.

SIDEBAR 3

Pharmacology Coverage in Dental Schools
Things have changed a great deal in the past 15 years in terms of dental pharmacology, observes D. Walter Cohen, Chancellor Emeritus of Drexel University College of Medicine and Dean Emeritus of the University of Pennsylvania School of Dental Medicine. As a result, dental students today are receiving much more information in the area of pharmacology than they ever did before.

There are more intense programs on the use of drugs for some areas, such as infection control, pain management, and anti-anxiety, he says. And although the current dental school curriculum provides more hours for pharmacology, Cohen notes that what tomorrow’s professionals are learning about pharmacology today is dependent upon the specific institution they’re attending.

“Dental students are given very significant pharmacology courses,” believes Ronald Kulinksi, DDS, BS Pharm, a former assistant professor and director of the Special Care/Geriatric Clinic at the University of North Carolina School of Dentistry. “Compared to 10 or 15 years ago, they’re covering similar things—mechanisms of action, clinical pharmacology, and dental pharmacotherapeutics—but the volume of drugs that they’re learning about is just that much more.”

What has changed in the classroom regarding dental pharmacology is the fact that dental students now really are given the background to understand how newer drugs fit into the dental environment, explains Morton Rosenberg, DMD, a professor of oral and maxillofacial surgery and head of the division of anesthesia and pain control at Tufts University School of Dental Medicine. Not only are they learning about medications that directly affect dental health, but they’re studying other medications that may interact with the drugs that practicing general dentists and specialists routinely administer, he says.

Not only has the volume of pharmacology information increased, but possibly the quality of information, if not the quality of the medications themselves. As Kulinski explains, while years ago dental professionals may have thought a drug’s mechanism of action was due to one receptor, it’s now understood that there could be receptors with four or five subtypes being affected by a medication. This, he says, is much more information for a dental student to understand and clarify.

“Pharmacology and therapeutics for dental students really involve two things: the drugs they prescribe (eg, local anesthetics, sedatives, analgesics, antibiotics) and how those drugs might interact with what the patient is already taking,” explains Paul Moore, DMD, PhD, MPH, chair of the department of dental anesthesiology and a professor of pharmacology at the University of Pittsburgh School of Dental Medicine. “It is much more rigorous that it was 20 years ago.”

SIDEBAR 4

The Inside Look FROM...

In each issue of Inside Dentistry, the publishers and staff strive to deliver clear, objective, and relevant reporting of the thought-provoking issues facing the dental profession. We gratefully acknowledge the following individuals, without whom this Inside look at dental pharmacology in today’s practice would not have been possible. Their candid comments and professional insights were invaluable to developing this timely presentation.

Academia

D. Walter Cohen, DDS
Chancellor Emeritus, Drexel University College of Medicine
Dean Emeritus, University of Pennsylvania School of Dental Medicine
jmitchel@DrexelMed.edu

Paul Moore, DMD, PhD, MPH
Professor of Pharmacology
Chair, Department of Dental Anesthesiology
University of Pittsburgh School of Dental Medicine
pam7@pitt.edu

Morton Rosenberg, DMD
Professor of Oral & Maxillofacial Surgery
Head, Division of Anesthesia & Pain Control
Tufts University School of Dental Medicine
morton.rosenberg@tufts.edu

Richard Wynn, BSPharm, MS, PhD
Professor of Pharmacology
University of Maryland Dental School
Wynnrx649@cs.com

Dental Practice

Ronald Kulinski, DDS, BS-Pharmacy
Director of Dental Medicine
Moses Cone Health Systems
ronald.kulinski@mosescone.com

Research Institutes

Raymond Dionne, DDS, PhD
Scientific Director, Division of Intramural Research
National Institute of Nursing Research
dionner@mail.nih.gov

Industry

Michael Cavanaugh, MBA
Executive Director of Marketing
OraPharma
MCavana@cpcus.jnj.com

Margaret Scarlett, DMD
President
Scarlett Consulting International
info@scarlettconsulting.com