INTRODUCTION

Implementing evidence-based oral health practices is essential to the general health and quality of life of patients. ¹ Dentists are at the core of these practices; they are required to make tailored clinical decisions, combining surgical/operative interventions and medications to treat any condition affecting oral health. Their role is essential in providing high-quality dental care and personalized quality use of medicines, taking into account the clinical context and other medications patients take. Therefore, dentists should continuously improve their knowledge, competencies, and practice about medications, such as their side effects, contraindications, and interactions, to define the best treatment for each patient. ² Studies around the world revealed numerous prescription errors (e.g., wrong molecules, doses, or treatment duration, inadequate prescriptions in special populations such as the elderly and children), leading to detrimental outcomes on patient care: misuse and abuse of opioids, antimicrobial resistance leading to complications and prolonged hospitalizations, potential harm and adverse drug reactions related to drug-drug interactions, increased unnecessary pharmaceutical expenditures and costs, especially in an already overburdened healthcare system such as in Lebanon. ³ - ¹² Reports from Lebanon highlighted inappropriate drug prescribing, denoting the persistence of this problem throughout the years. ¹¹ To our knowledge, studies assessing inappropriate prescribing practices among dental care providers in Lebanon are scarce, and the few studies available have focused on antibiotics, when the problem encompasses other medications. ¹¹ , ¹³ Moreover, the lack of national treatment guidelines makes dentists rely on various international guidelines, which might be different sometimes, resulting in confusion among prescribers. ¹⁴

For all these reasons, identifying contributing factors to inappropriate drug prescribing in Lebanon would help us better shape the size of the problem and implement a clear strategic plan to improve prescription practice and raise awareness of dentists about the proper use of medications. The ultimate goal would be to establish policies to promote the critical role of dentists in medication safety.

Therefore, the primary objective of our study was to assess drug-prescribing perception, practices, in addition to drug-related educational needs among dental care providers in Lebanon. The secondary objective was to evaluate the need for further interprofessional collaboration between dentists and pharmacists regarding medications and oral health.

METHODS

RESULTS

A total of 137 dentists completed the online survey. The mean age of participants was 42.17 (SD 13.78) years, and 59% were females. Almost half of the sample had an academic activity (53.3%) and more than 12 years of experience (56.9%). Table 1 summarizes the socio-demographic and socioeconomic characteristics of the participants.

The mean self-confidence in prescribing drugs index was 26.69 (SD 7.06) (median=27; minimum=9; maximum=42) and that of the confidence in pharmacists 9.40 (SD 2.39) (median=10; minimum=4; maximum=15).

Table 2 presents the results of the dentists' perception of prescribing practice. The majority of dental care providers considered that they have fair to good perceived knowledge in pharmacology and therapeutics (80.3%), but only 30.7% reported to be sufficiently equipped to prescribe safely (strongly agree/agree). Prescribing for older patients, dosing, medication use in pregnancy, avoiding drug interactions, and assessing adverse reactions (explore whether the side effect reported by the patients might be related to a prescribed drug and report it to the pharmacovigilance system), were associated with low percentages of perceived knowledge ( Table 2 ).

Figure 1 summarizes the level of confidence of dentists in prescribing. The highest level of confidence was noted for prescribing to patients with gastrointestinal symptoms, cardiovascular diseases, and endocrine/metabolic diseases (strongly agree/agree: 57.7%, 51.1%, and 44.5%, respectively), while the lowest level was expressed with patients with organ impairment, cancer, and neurological disorders (disagree/strongly disagree: 53.3%, 48.9%, and 46.7%, respectively).

Figure 1.  Level of confidence of dentists when prescribing to special populations or patients with particular diseases†Diseases as detailed in the questionnaires: Neurological disorders such as epilepsy, Parkinson's disease; Organ impairment such as impaired liver or renal functions; Respiratory diseases such as asthma and chronic obstructive pulmonary disease; Gastrointestinal symptoms such as gastric or duodenal ulcer; Endocrine & metabolic diseases such as hypothyroidism, diabetes, high blood pressure. 

The most prescribed drug classes included mainly antibiotics (87.6%), analgesics (86.9%), and nonsteroidal anti-inflammatory drugs (NSAIDs) (82.5%). Most dentists turned to pharmaceutical companies and medical representatives (78.8% and 54.7%) to get information on medications; they also considered electronic references/databases, medical journals, and clinical pharmacists as reliable sources for information ( Table 3 ). The majority of dentists used drug information to manage their patients (78.1%), but only 64.3% reported routinely checking a reference before prescribing (strongly agree/agree), even though almost 61% disagreed on having difficulties getting any drug information (disagree/strongly disagree). The most common prescribing incidents were the lack of data regarding patients' allergies (54%) and wrong treatment duration (46.7%). Most dentists declared spending no more than 10 minutes explaining the drug regimen to patients ( Table 3 ).

The majority of dentists considered that seminars and close collaboration with pharmacists were the primary sources to update their information about medications, and 76.6% agreed on the importance of including pharmacology courses in the dental curriculum. The majority (61.3%) considered that oral health counseling should be provided in community pharmacies, but only 52.6% encouraged patients to talk to pharmacists about their medications ( Table 4 ). Moreover, only 15% of dentists thought that their patients got enough counseling from their pharmacist about oral health; the majority did not consider this to be the case or did not know.

A higher mean self-confidence in prescribing and a higher mean confidence in pharmacists were found in dentists who did not specialize in periodontics compared to those who did (28.03 vs. 23.96 and 9.84 vs. 8.51, respectively) ( Table 5 ).

The results of a first logistic regression, taking the dichotomous dentist's self-confidence in prescribing drugs score as the dependent variable, showed that specializing in periodontics was significantly associated with lower odds of having self-confidence in prescribing drugs (aOR=0.25) and having confidence in the pharmacist (aOR=0.45) ( Table 6 ).

DISCUSSION

This study assessed dentists' perception, practice, and confidence in prescribing drugs. Almost all participants considered they had fair to good perceived knowledge in pharmacology and therapeutics, but very few thought they had sufficient training to prescribe medications safely. This discrepancy might be related to the misleading information they might be getting from different sources. Indeed, in our study, pharmaceutical companies and medical representatives ranked first as sources of information on medications. Previous reports from Lebanon had highlighted the influence the pharmaceutical industry has on medical education activities, probably to promote a culture of acceptance. ¹¹ However, dentists should not forget that the pharmaceutical industry can influence prescribing habits, sometimes leading to less rational and lower quality prescribing, with higher prescribing costs and risks since harmful effects of drugs are often missing in the promotional presentations. ¹¹ , ¹⁷ This "bioethical" perspective on drug promotion should be implemented at the undergraduate level, and practitioners should be encouraged to seek information from more reliable sources. ¹¹ Another explanation of this discrepancy could be related to the lack of training on translating pharmacological knowledge into clinical practice. A recent study exploring the effect of a multimodal intervention on prescribing practices showed that targeted education and the use of educational prescribing websites would improve knowledge and confidence among practitioners. ¹⁸ Such an approach, along with the integration of more pharmacology courses in the dental curriculum, as suggested by the vast majority of our sample, would enhance their trust in drug prescription, particularly in antibiotics and analgesics, the most reported prescribed drugs in our study.

Regarding antibiotics, the lack of confidence and low perceived knowledge identified in our study was similar to previous national and international findings in terms of adherence to antibiotic stewardship. ³ , ¹³ , ¹⁴ , ¹⁹ The lowest level of confidence among dentists specialized in periodontics was also described previously. ⁷

Inappropriate antibiotic prescriptions can lead to detrimental consequences, such as increased resistance, development of multidrug-resistant organisms, waste in healthcare resources and expenditures, and a higher number of adverse events, including the emergence of C. difficile . ³ , ¹⁴ Unfortunately, in Lebanon, national guidelines for antibiotic prescription in dentistry are lacking, and the National Antibiotic Resistance Committee at the Ministry of Public Health failed at establishing a clear strategic plan to curb antibiotic resistance. ¹⁴ Moreover, this committee does not include dental care practitioners among its members. Therefore, in such a complex environment, educational interventions (whether at the pre-graduate or post-graduate levels) are crucial to help dentists understand and apply the latest guidelines to improve antibiotic selection practices. ³ , ²⁰ - ²²

As for analgesics, while pain management is essential in dental practice, dentists, periodontists, in particular, should be aware of the risks of opioid misuse and abuse. Indeed, implants and periodontal procedures were among the four dental procedures that require the highest doses of opioids after adjusting for patients' characteristics. ⁷ Periodontists should know when to use them in case of persistent or severe pain or look for other therapeutic options, such as non-narcotic analgesics recommended as a first-line treatment, with guidelines agreeing on their better safety and efficacy than opioids. ⁷ , ²³ , ²⁴ Specific data on opioid abuse/misuse related to dental prescription lacks in Lebanon. However, acknowledging their inherent risks, weak opioids such as codeine and tramadol were classified as controlled drugs and cannot be dispensed by pharmacists without a doctor's prescription, including dentists. ²⁵ , ²⁶ Despite this restriction in Lebanon, local data from a pharmacist's perspective expressed the need for better supervision on sales and better governmental regulations to limit possible misuse or abuse. ²⁶ In addition to opioids, clinicians should acknowledge the toxicity of NSAIDs and their potential interactions and adverse effects, especially that, in Lebanon, these medications are available over-the-counter. Therefore, dentists should advise their patients to avoid self-medication and should be extremely cautious when prescribing this class of analgesics in older patients, in patients with gastrointestinal problems, or taking aspirin, oral anticoagulants (vitamin K antagonists), or corticosteroids, due to the risk of gastric bleeding and peptic ulcer disease. ⁴ , ⁹

Besides the specific drug classes, dentists exhibited low perceived knowledge about prescribing in elderly patients, dosing, medication use in pregnancy, drug interactions, and adverse reactions. Moreover, their confidence in prescribing was the lowest in patients with organ impairment, cancer, and neurological disorders. This point is problematic, as several physiological changes can occur, whether in pharmacokinetics or pharmacodynamics of drugs, in these specific populations, with complex medical conditions and taking multiple medications. ⁴ , ²⁷ A study using the Beers criteria to identify potentially age-inappropriate medications among elderly dental patients had found that 56.9% of prescriptions had at least 1 Beers Criteria medication, and 28.3% involved two or more Beers Criteria medications, including drugs negatively affecting patient safety and oral health care. ⁴

Drug-induced oral adverse effects are manifold and include xerostomia (opioids, anticholinergic antidepressants, first-generation anti-histamine, benzodiazepine), taste alteration (amitriptyline, aripiprazole, olanzapine, quetiapine), bruxism (quetiapine and paroxetine), gingival overgrowth (nifedipine and phenytoin), higher risk of bleeding (oral anticoagulants), and osteonecrosis of the jaw (bisphosphonates, denosumab, antiangiogenic agents). ¹⁰ , ²⁸ , ²⁹ In our study, the majority of participants admitted spending no more than 5-10 minutes to prescribe/explain a drug regimen, a relatively short time to also check for drug interactions with medications the patient is taking.

CONCLUSIONS

Lebanese dentists reported some lack of knowledge and confidence in prescribing, particularly to specific populations. Education, training, and close collaboration between pharmacists and dental healthcare professionals are essential to overcome these problems and avoid potentially harmful effects due to prescribing errors, medication misuse, or drug interactions.