Dental Postgraduate Section · 2017. 10. 23. · Dental Postgraduate Section Wales Deanery 8th...

Dental Postgraduate Section Wales Deanery

8th Floor Neuadd Meirionnydd Heath Park Cardiff CF14 4YS

[email protected] T +44 (0) 29 20687780

Director: Professor David Thomas

2017 Dear Colleague, RE: An Audit of Antimicrobial Prescribing for Dentists working in General Practice in

Wales Professional bodies agree that all prescribers need to improve antimicrobial prescribing. It is

essential that the use of such drugs is evidence–based, and that each prescription must be

for the most appropriate drug, at the right dose for the correct duration.

The Dental Postgraduate Section, Wales Deanery in collaboration with 1000 Lives Plus have

developed an antimicrobial prescribing audit for dentists. It has been developed and tested

by GDPs in Wales.

The aims of this audit are to:

1. Support the most effective clinical use of antimicrobials

2. Reduce the number of unnecessary prescriptions.

This audit pack includes everything you need to undertake the audit and to qualify for 3 hours

verifiable CPD and associated funding (£195.21) for dentists with an NHS Performer Number.

You will need to register for the audit and submit your data electronically (see step 1, page

1).

We hope you find the audit a constructive way to learn and to ensure your antimicrobial

prescribing is as effective as possible.

Yours sincerely,

David Thomas Mrs Lisa Howells

Director Faculty Lead for Dentistry

Dental Postgraduate Education in Wales 1000 Lives Plus

mailto:[email protected]

Dental Postgraduate Section Wales Deanery 8th Floor Neuadd Meirionnydd Heath Park Cardiff CF14 4YS T +44 (0) 29 20687780 https://dental.walesdeanery.org Version 10: 25/01/16 Page 1 of 11

An audit of Antimicrobial Prescribing for Dentists working

in General Practice

This audit has been produced as part of the 1000 Lives Plus programme to support effective

antimicrobial prescribing by dentists in Wales.

The 1000 Lives Plus website can be accessed at www.1000livesplus.wales.nhs.uk

Dentists are responsible for almost 10% of all antimicrobial prescribing in Wales1 Holyfield, G

and Karki, A (2009) Review of prescribing by dentists in Wales. National Public Health Service

for Wales (now Public Health Wales).

www.wales.nhs.uk/sites3/docopen.cfm?orgid=781&id=171036

Professional bodies agree that all prescribers need to improve antimicrobial prescribing. It is

essential that the use of such drugs is evidence–based and that each prescription must be for

the most appropriate drug, at the right dose for the correct duration.

It is now accepted that the inappropriate and unnecessary use of antimicrobials in the

past is responsible for the present emergence of drug resistant strains of micro-

organisms, such as MRSA, both within an individual and within populations. More

recently and importantly, it has been demonstrated that improved prescribing habits by

individual practitioners can lead to a reduction of antimicrobial resistance within the

population.

The School of Postgraduate Medical and Dental Education and the School of Dentistry of Cardiff

University in collaboration with 1000 Lives Plus have developed an antimicrobial prescribing

audit for dentists.

The aims of this audit are –

To support the most effective clinical use of antimicrobials, and

To reduce the number of unnecessary prescriptions.

Step 1 - Register your audit using form AMP 1 which is included in this information pack

Every dentist in the practice or group of practices will need to register and start/finish the

audit at the same time.

To undertake this audit, you need to register by sending your AMP 1 form to Heather Stewart

([email protected]) and complete the audit fully to qualify for 3 hours verifiable CPD and

associated funding for dentists with an NHS performer number.

https://dental.walesdeanery.org/http://www.1000livesplus.wales.nhs.uk/http://www.wales.nhs.uk/sites3/docopen.cfm?orgid=781&id=171036


At registration you will be allocated a unique identifier number so that you can receive prescribing

data feedback.

Step 2

Familiarise yourself with guidance on evidence based prescribing and the standards for this

audit.

Dentists are able to prescribe a wide range of antimicrobials within the NHS, as listed in the

BNF. However a Clinical Guide - specially developed for Dentists - is available in Wales to

support safer and more effective prescribing.

Scottish Dental Clinical Effectiveness Programme (2011) Drug Prescribing For Dentistry: Dental

Clinical Guidance. 2nd Ed http://www.sdcep.org.uk/index.aspx?o=3130

Dentists in Wales can access and use this Clinical Guidance. The tables on pages 4 to 9 below

give an outline summary of the advice on antimicrobial prescribing. This is the standard against

which this audit will be measured.

Evidence shows that dentists sometimes prescribe inappropriately – for example after routine

extractions or deep scaling, or after deep restorations. Sometimes antimicrobials are

prescribed without undertaking any other appropriate clinical interventions. The summary

outlines evidence based prescribing in respect of the patient’s condition and the medication.

Step 3

Data collection

Data is collected in hard copy on form AMP 2 and on-line

Complete a hard copy and on-line form for every patient you prescribe antimicrobial

medication (s).

You may prescribe for the patient’s presenting condition, or for an incidental finding.

Each patient counts as one entry on the form, regardless of how many medications have been

prescribed.

This audit requires you to complete 20 forms or collect data for a period of 3 months

from registering the audit – whichever is first.

Hard copy

A printable form AMP 2 is attached. Print a maximum of 20 forms. These remain with you and

can be used at any practice you work in. You will need this data when you come to reflect on

your prescribing.

Forms have space for unique patient identifier. You can use any suitable identifier that allows

you to check back against the patient’s notes, including the patient’s name since these forms

remain with you and are not shared with anyone.

https://dental.walesdeanery.org/http://www.sdcep.org.uk/index.aspx?o=3130


On-line – https://cardiff.onlinesurveys.ac.uk/1000livesdentalwales You have been given a unique identifier number. This must be entered on the form.

The data will be collated and each practice will receive feedback on the prescribing profile.

Individual dentist prescribing data will remain strictly confidential and the findings used only as

collated anonymised figures for Wales.

The on-line form does not include any individual patient data or identifier.

This audit does not distinguish between tablets, capsules, oral solutions, oral suspensions etc.

You will not be asked for this information

This audit mostly uses generic names – it does not include all brand names. If you have

prescribed a brand name please record under the generic name.

This audit does not ask for the patient’s age. It includes the full range of medication doses and

can be used for patients of all ages – including children.

This audit does not include mouthwashes (such as chlorhexidene) which may be prescribed

alone or in addition to other medication.

The data will be collated and the practice will receive feedback on prescribing activity

when data has been received on 20 patients per dentist or after a period of 3 months

from registering the audit – whichever is first.

Remember to include your practice team in the audit:

- Discuss the audit at team meetings, particularly the importance of reducing antimicrobial

prescribing

- To include DCPs appropriately in recording the prescribing data

- Encourage DCPs to reinforce dentists advice on the importance of taking medication as

directed, and what patients should do in the event of suspected allergic reaction

- Consider a DCP led audit to ensure that all patient records include history of allergies to

medication / antimicrobials – and that allergies are clearly “flagged”.

Step 4

On receipt of feedback you must reflect on your prescribing activity – individually and

collaboratively with group members. Your hard copy data will support this stage.

Some points to consider –

Is your prescribing is in line with the Clinical Guide?

Was your diagnosis clear, and were antimicrobials really necessary?

Were other appropriate interventions carried out?

If antimicrobials were necessary, was the correct drug prescribed at the right dose and

duration?

Do you need to make changes to your antimicrobial prescribing?

https://dental.walesdeanery.org/https://cardiff.onlinesurveys.ac.uk/1000livesdentalwales


A number of prescribing case studies are attached. They may be useful when discussing your

prescribing.

Following this reflection, every dentist must complete the attached feedback form (AMP 3) and

claim form (AMP 4) and return to Heather Stewart. AMP 4 must be completed as hard copy to

comply with funding protocol. This completes the audit cycle and ensures funding for dentists

with an NHS number, and verifiable CPD for all dentists. It is recommended that these are

submitted no later than 6 months from the audit completion date. Payment will be processed

when all dentists in the group have submitted forms AMP3 and 4.

Re-audit

Re-audit your prescribing 6 to 9 months after completion of first audit cycle to ensure you have

embedded the identified changes into your prescribing practice.

If you would like to keep “day to day” information on your prescribing you can use an electronic run chart which will be sent to you when you complete the audit. The run chart is for use in the practice only and does not have to be shared with anyone. It collates your prescribing data and provides weekly or monthly summaries.

Need Help?

If you require help with any aspects of this audit, contact Heather Stewart who will direct you to

an appropriate tutor if necessary.

References

1.Holyfield, G and Karki, A (2009) Review of prescribing by dentists in Wales. National Public

Health Service for Wales (now Public Health Wales)

www.wales.nhs.uk/sites3/docopen.cfm?orgid=781&id=171036

2. Scottish Dental Clinical Effectiveness Programme (2011) Drug Prescribing For Dentistry:

Dental Clinical Guidance. 2nd Ed http://www.sdcep.org.uk/index.aspx?o=3130

https://dental.walesdeanery.org/http://www.wales.nhs.uk/sites3/docopen.cfm?orgid=781&id=171036http://www.sdcep.org.uk/index.aspx?o=3130


Table of antimicrobials (taken from SCDEP2)

This table does not include information on drug interactions, or factors relating to

patient’s general medical history. The patient’s medical and drug history must be

checked prior to prescribing any medication.

Reason for prescribing Drug Dosage (adults)

Dosage (children)

Duration

Dental abscess: If local measures have proved ineffective or there is evidence of cellulitis, spreading infection or systemic involvement. *if allergic to penicillin #If patients do not respond to first-line amoxicillin or metronidazole treatment, or in cases of severe infection with spreading cellulitis. Refer patients to hospital if they have severe swelling that may compromise the airway

Amoxicillin Capsules

250 mg: 1, 3X daily

BNF 66 September 2013 has revised the recommended dose to 500 mg TDS. This is not yet noted in other guidance.

Or Oral Suspension*, 125 mg/5 ml or 250 mg/5 ml 6 months - 1 year: 62.5mg, 3X daily 1-5 years: 125 mg, 3X daily 5-18 years: 250 mg, 3X daily

5 days

Phenoxymethylpenicillin Tablets

250mg: 2, 4X daily

Or Oral Solution, 125 mg/5 ml or 250 mg/5 ml 6 months - 1 year: 62.5 mg 4X daily 1-6 years: 125 mg 4X daily 6-12 years 250 mg: 4X daily 12-18 years: 500 mg 4X daily

5 days

*Metronidazole Tablets 200mg: 1, 3X daily

Or Oral Suspension, 200 mg/5 ml 1-3 years: 50 mg 3X daily 3-7 years: 100 mg 2X daily 7-10 years: 100 mg 3X daily 10-18 years: 200 mg 3X daily

5 days

*Erythromycin Tablets 250mg: 1, 4X daily

Or Oral Suspension, 125 mg/5 ml 6 months - 2 years: 125 mg 4X daily

5 days

https://dental.walesdeanery.org/


2-18 years: 250 mg 4X daily

#Clindamycin Capsules 150mg: 1, 4X daily

12-18 years: As for adults

5 days

#Co-amoxiclav Tablets 250/125mg: 1, 3X daily

12-18 years: As for adults

5 days

#Clarithromycin Tablets 250mg: 1, 3X daily

Or Oral Suspension 125 mg/5ml or 250 mg/5 ml 1-5 years (Body weight 12-19 kg): 125 mg 2X daily 5-12 years (Body weight 20-29 kg): 187.5 mg 2X daily 12-18 years: 250 mg 2X daily

7 days

Acute necrotising ulcerative gingivitis Pericoronitis: where there is systemic involvement or persistent swelling despite local measures.

Metronidazole Tablets 200mg: 1, 3X daily

Or Oral Suspension, 200 mg/5 ml 1-3 years: 50 mg 3X daily 3-7 years: 100 mg 2X daily 7-10 years: 100 mg 3X daily 10-18 years: 200 mg 3X daily

3 days

Amoxicillin Capsules 250mg: 1, 3X daily

Or Oral Suspension, 125 mg/5 ml or 250 mg/5 ml 6 months - 1 year: 62.5mg 3X daily 1-5 years: 125 mg 3X daily 5-18 years: 250 mg 3X daily

3 days

Sinusitis: Antibiotic therapy should only be used for persistent symptoms and/or purulent discharge lasting at least seven days or if symptoms are severe. *OR if an antibiotic is required.

Ephedrine Nasal Drops 0.5%

10ml: 1 drop in each nostril up to 3X daily

12-18 years As for adults

7 days

*Amoxicillin Capsules

250mg: 1, 3X daily

Or Oral Suspension*, 125 mg/5 ml or 250 mg/5 ml 6 months - 1 year: 62.5mg 3X daily 1-5 years: 125 mg 3X daily 5-18 years: 250 mg 3X daily

7 days



*Doxycycline Capsules

100mg: 1 2x 1st day, 1 daily after


Where the condition is bacterial in nature sodium fusidate (fusidic acid) ointment can be used. *For unresponsive cases

have healed

Sodium Fusidate Ointment, 2%

15g: Apply to angles of mouth 4X daily.

As for adults

Do not prescribe sodium fusidate for longer than 10 days

*Miconazole (2%) and Hydrocortisone (1%) Cream


As for adults

Continue use for a maximum of 7 days

*Miconazole (2%) and Hydrocortisone (1%) Ointment


As for adults

Continue use for a maximum of 7 days

Primary herpetic gingivostomatitis [as a result of herpes simplex virus (HSV)]: Mild infection of the lips [herpes labialis (cold sores)] in non-immuncompromised patients is treated with a topical antiviral drug. Refer immunocompromised patients (both adults and children) with severe infection to hospital. *For infections in immunocompromised patients and severe infections in non-immunocompromised patients. #In prodromal stages.

* Aciclovir Tablets 200 mg: 5X daily

Or Oral Suspension, 200 mg/5 ml 6 months - 2 years: 100 mg 5X daily 2-18 years: 200 mg 5X daily

5 days

# Aciclovir Cream, 5% 2g: Apply to lesion every 4 hours 5X daily

As for adults 5 days

# Penciclovir Cream, 1%

2g: Apply to lesions every 2 hours during waking


Case Studies Scenarios

For all following scenarios consider your first line approach:

1. What is the likely diagnosis? 2. What treatment/intervention would you carry out? 3. Why would/wouldn’t you prescribe? 4. What, if any antimicrobial would you prescribe? 5. What dose/duration? 1. Adult patient has severe pain and localised swelling from UR5 which has a

large leaking amalgam filling and is TTP. 2. Adult patient has severe pain and swelling from a non carious impacted

LR8. Also has trismus and lymphadenopathy. 3. Adult patient with a large fluctuant swelling extending under the right eye

associated with a root filled UR2. Patient’s temperature is raised. 4. Adult patient in severe pain since previous day. Continual ache, kept

awake all night. Analgesics ineffective. Pain is associated with a grossly carious UR6.

5. Adult patient with painful bleeding gums, ulceration and flattening of inter

dental papillae and bad breath.

6. Adult patient with sore bleeding gums. Patient has poor oral hygiene, plaque and bop scores both 60%+ .

7. Adult patient with grossly neglected mouth and poor motivation has severe

pain and localised swelling at LL6 which is a caries/restoration free tooth with grade 3 mobility and severe recession. Patient allergic to penicillin.

8. 4 year old child with severe constant pain from UR E which is grossly

decayed. Kept awake all night. Patient is extremely distressed and non



compliant. Attempts to carry out treatment have been unsuccessful. 9. A 70 year old patient taking oral bisphosphonates for the previous 2 years

is in severe pain from a grade 3 mobile, grossly decayed LL5.

10. A 69 year old male presenting with pain from LR6. Tooth TTP and grade 3 mobile. He has a medical history of past infective carditis and his son is a consultant cardiologist in Cardiff, who has stressed antibiotic cover regime.



Case Studies Diagnosis Answers

Probable Diagnosis

Treatment intervention

Why/Why Not Prescribe?

Antimicrobial: Dose and Duration

Comments

1 Non vital tooth peri radicular infection

Options for XLA/ RCT.

Only If severe enough swelling?

Amoxycillin 250mg TDS 5 days

2 Pericoronitis Probably Rx Local irrigation

Possible systemic involvement

Metronidazole 200mg TDS, 3 days

3 Failed root canal treatment with periapical infection

Incision and drainage

Systemic involvement

Amoxycillin 250mg TDA, 5 day course.

Consider combination with metronidazole 200mg.

? double dose of amoxicillin if severe enough.

4 Irreversible pulpitis Options RCT/XLA

Not necessary or appropriate.

Pain will go with correct intervention.

5 ANUG Rx metro/ hydrogen peroxide

Metronidazole H2o2

9 tabs 200mg tds 3 days. 6% h2o2

6 Periodontal disease Initial phase OHI Scaling If onto phase 2 could consider Rx

Not necessary or appropriate

7 Periodontal abcess Extract tooth Not necessary or appropriate.

Infection will clear once tooth extracted.



Probable Diagnosis

Treatment intervention

Why/Why Not Prescribe?

Antimicrobial: Dose and Duration.

Comments

8 IrreversiblePulpitis/periapical infection, deciduous tooth

Arrange GA ? (Rx amox sugar free 125mg/5ml. tds) WRONG according to standards, but worth discussing!) Paracetamol 240mg Qds OK for mild-moderate pain.

SDCEP would suggest Rx inappropriate here.

? consider amoxil if urgent GA not possible.

9 Decay/ periradicilur infection XLA, as non invasive as possible. Stress infection risk, and requirement to review/ keep close check on xla site

No antibiotics. Rx corsodyl

300mls chlorohexidine gluconate 0.2% twice daily and pre extraction may be useful.

Give appropriate post-operative advice.

Antibiotic cover for bisphosphonates not required

10 Periodontal abcess Extraction is required.

no Main problem is NICE , discuss plan for tooth, if xla then contact patient’s son stressing practice protocol. If he wants ABC, ensure he is responsible for provision and supervision. Check



with your Indemnity Society if in doubt.


Dental Postgraduate Section · 2017. 10. 23. · Dental Postgraduate Section Wales Deanery 8th...

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