Dentist’s ‘alarming misunderstanding’ of pharmacist role

A dentist has been reprimanded after prescribing benzodiazepines to a two-year-old and a seven-year-old who both later presented to emergency departments

A NSW Civil and Administrative Tribunal hearing has heard that a dentist inappropriately prescribed lorazepam to a two-year-old patient who had been brought to the dental practice by her mother in late 2015.

The toddler was in pain and could not eat, but the dentist had difficulty examining her because she would not sit still.

When he suggested the mother take her to a paediatric dentist, she replied that she could not afford to do so. The dentist discussed treatment with the mother and told her that the girl would need to be sedated, but that he could not administer a sedative through a mask given how active the patient was.

“He looked up the Australian Medicines Handbook and it seemed lorazepam was the most suitable option because in limited circumstances it could be used pre-surgically, and he prescribed 1mg lorazepam to be taken 1 hour before Patient A’s dental appointment,” the Tribunal noted.

“He prescribed oral antibiotics to treat the infection under the tooth.”

When the mother brought the toddler back to the surgery for treatment, the girl was still “very active” despite having taken 1mg lorazepam.

The dentist suggested a second tablet, but when there was no sedative effect after an hour, the surgery did not proceed.

Five days later, the mother phoned the dentist to say that the child had been taken to Emergency and had recovered.

“The result of the administration of two 1mg tablets to a 2 year old was a reaction consistent with overdose, which MIMS describes as usually manifested by degrees of central nervous system depression ranging from drowsiness to coma,” the Tribunal noted.

The dentist acknowledged that he had not adequately assessed the girl when prescribing the medication, based on age and weight.

He also “did not have adequate knowledge in relation to benzodiazepines, or provide instructions explaining the nature and risk of that treatment; he did not arrange adequate follow up care; he was not aware of his limitations regarding the pharmacological aspects of treating paediatric patients; he made an incorrect assumption that if Lorazepam was unsuitable for paediatric use the pharmacist would not have administered the medication or would have informed him; and he failed to make and keep adequate clinical records”.

The second patient was a seven-year-old who was prescribed benzodiazepines before treatment on two dates in late 2014, at a different practice.

The dentist prescribed benzodiazepines but the mother came back and said she had lost the script; a script for temazepam was issued by another dentist at the practice between the two surgery dates. This patient took the medication an hour before treatment on the second date, which was conducted and the patient discharged.

The patient presented at Emergency that evening, with “what was recorded as side effects of lorazepam,” the Tribunal noted.

The dentist said he had prescribed lorazepam for the patient after her mother said he would prefer that he treat her, rather than referring to a paediatric specialist, which the mother could not afford.

He said that he administered lorazepam instead of temazepam as the latter “had had very little sedative effect”.

An expert testified that the prescription of lorazepam by the dentist in question and temazepam by his colleague were “entirely inappropriate without having protocols in place for written information, informed consent, dispensing and monitoring”.

The expert said that the dentist’s “knowledge of and his practice of dentistry in relation to oral sedation of children was manifestly inadequate”.

The Health Care Complaints Commission submitted that he exhibited “a concerning lack of knowledge as to the effects of the interaction between antibiotics and other medications, and an alarming misunderstanding in respect of the role of pharmacists”.

The Dental Council felt that “a degree of arrogance and overconfidence” was present in the dentist’s actions, but the dentist said that he prescribed the medications “mainly due to lack of knowledge, and what he described as a ‘massive gap’ in his knowledge around prescribing and pharmaceuticals,” the Tribunal noted.

It noted that rather than arrogance, the dentist relied on “formulaic’ approaches to practice and patient treatment which was consistent with a lack of knowledge and thought.

It said this was demonstrated in the dentist’s approach to the prescription of antibiotics.

Prescribing records showed that he “routinely prescribed Flagyl (metronidazole) 400mg three times a day rather than 200mg, and 500mg amoxicillin rather than 250mg,” it noted.

“In his oral evidence on 9 July 2018, notwithstanding his stated understanding of the risks of antibiotic resistance, [the dentist] stated that he prescribed the higher dose of metronidoazole because it has been effective and periodontics colleagues stated that that is what they prescribe, and that he prescribed the strongest dose of Augmentin Duo Forte when he needed to give antibiotics to someone who had a pretty severe infection.

“He acknowledged that he relied on the pharmacist to give his patients specific instructions about the medications prescribed.”

The dentist said that he had demonstrated insight into his mistakes and limitations, and had prioritised his professional development and education.

“He regrets his errors explaining that it was his misguided desire to help his patients which led to his administering lorazepam rather than referring the patients, and he has committed to making sure he is a better dentist,” the Tribunal noted.

The dentist was reprimanded and conditions placed on his registration, including that he not prescribe S8 or S4D drugs for patients until changes have been made to his S8 and S4D authority, which would need to take place under consultation with the Dental Council of NSW.

He is also to practice under supervision, to submit to an audit of his practice, complete professional education and pay court costs.

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  1. Jarrod McMaugh

    “he made an incorrect assumption that if Lorazepam was unsuitable for paediatric use the pharmacist would not have administered the medication or would have informed him”

    How is this an incorrect assumption? This is exactly what the pharmacist in this case should have done!

    • Curtis Watson

      What are the chances that the patients date of birth and the indication for use were written on this particular prescription?
      Does this excuse the lack of thorough counselling – absolutely not, but I bet it would have helped.

      • Jarrod McMaugh

        completely agree. As would an electronic health record.

  2. Amin-Reza Javanmard

    “The dentist said he had prescribed lorazepam for the patient after her mother said he would prefer that he treat her, rather than referring to a paediatric specialist, which the mother could not afford.”

    I think this is the deeper underlying problem…

  3. Bluex

    Unfortunately both side are to be blamed in this scenario.

  4. Cautious Cow

    Can we agree that PDL publishes these articles with the intent to educate all registered practitioners? What have we learned from your comments? Can dentists prescribe Lorazepam in your jurisdiction? Does the APF23/24 state Lorazepam’s paediatric premedication dose is 0.05mg/kg? Will the patient or prescriber faithfully follow written instructions? Are the statements made in defence of any complaint ever a true reflection of what actually transpired on the day? A forum that discusses better outcomes, based on workplace limitations and documented guidance would be nice.

  5. Anonymous

    The punishment the dentist received is too much compared to an incorrect prescription. I stopped a wrong script of amiloride for a patient on spironolactone last week. I think I saved the GP’s registration and spared an 80 years old patient hyperkalemia and hypotention. Who said that stopping incorrect prescriptions is not in the scope of the practice of pharmacists?! If so, let us then abolish the pharmacy profession and make NSW dental board happy.

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