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University of the Pacific Scholarly Commons School of and Health Sciences Faculty Thomas J. Long School of Pharmacy and Health Articles Sciences

10-1-2015 and pharmacists: paradigm shifts and interprofessional collaborative practice models Cynthia S. Valle-Oseguera University of the Pacific

Eric G. Boyce University of the Pacific, [email protected]

Follow this and additional works at: https://scholarlycommons.pacific.edu/phs-facarticles Part of the and Health Sciences Commons

Recommended Citation Valle-Oseguera, C. S., & Boyce, E. G. (2015). Dentists and pharmacists: paradigm shifts nda interprofessional collaborative practice models. Journal of the California Dental Association, 43(10), 591–595. https://scholarlycommons.pacific.edu/phs-facarticles/265

This Article is brought to you for free and open access by the Thomas J. Long School of Pharmacy and Health Sciences at Scholarly Commons. It has been accepted for inclusion in School of Pharmacy and Health Sciences Faculty Articles by an authorized administrator of Scholarly Commons. For more information, please contact [email protected]. collaboration

CDA JOURNAL, VOL 43, Nº10

Dentists and Pharmacists: Paradigm Shifts and Interprofessional Collaborative Practice Models

Cynthia Valle-Oseguera, PharmD, and Eric G. Boyce, PharmD

ABSTRACT Collaborations between dentists and pharmacists have the potential to improve patient care; however, there are limited examples in practice of interprofessional models between these disciplines. The purpose of this article is to explore the current relationship between dentists and pharmacists and to propose new models of interprofessional collaboration that target improvements in patient care.

AUTHORS

Cynthia Valle-Oseguera, Eric G. Boyce, PharmD, ealth care continues to current relationship between these PharmD, is an assistant is associate dean for evolve and move toward professionals appears to be limited professor of pharmacy academic aff airs and improvements in quality to phone calls regarding ordering of practice at the University a pharmacy practice of the Pacifi c in Stockton, professor at the University of of patient-centered care prescriptions, prescription clarifi cation Calif. Her professional the Pacifi c in Stockton, Calif. through interprofessional and modifi cation due to areas of interest include His professional areas of Hcollaboration among different coverage or when medically necessary. interprofessional , interest include educational disciplines. The Institute of Medicine However, there are many other areas, chronic state outcomes, assessment and (IOM) has designated interprofessional including prevention and treatment management and . pharmacy leadership. Confl ict of Interest collaboration as one of the fi ve core of and management, in Confl ict of Interest Disclosure: None reported. competencies that every which patient care can be enhanced Disclosure: None reported. professional should meet during the through interprofessional collaborations provision of care and irrespective between dentists and pharmacists. of their discipline.1 Collaborations Both disciplines are faced with between dentists and pharmacists unique challenges that have potential have the potential to improve patient for improvement if both care, but there are limited examples work collaboratively. In order to achieve in practice of interprofessional models meaningful collaborations, team between these disciplines. This participants should desire to work in may be related to perceptions that partnerships, possess shared respect and disconnect oral health from overall trust and have an understanding of each health, often regarding the former as other’s roles.3,4 An important obstacle for a luxury and failing to appreciate its both professions is their limited physical impact on overall well-being.2 The interaction with other professionals.

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TABLE The General Responsibilities of Dentists and Pharmacists According to the American Dental Association and the American Association of Colleges of Pharmacy10, 11

Dentists’ Responsibilities10 Pharmacists’ Responsibilities11 Pharmacists’ Goals11 Diagnosing oral . Dispensing medications. Cure disease. Promoting oral health and disease prevention. Monitoring patients’ health and progress to Eliminate or reduce symptoms. maximize their response to the medication. Creating treatment plans to maintain or restore oral Educating patients on the use of prescriptions and Arrest or slow a disease process. health. over-the-counter medications. Interpreting X-rays and diagnostic tests. Advising , nurses and other health Prevent disease. professionals on drug decisions. Ensuring the safe administration of anesthetics. Recognize disease. Monitoring growth and development of teeth and jaws. Performing surgical procedures on the teeth, Alter physiological processes for desirable result in and soft tissues of the oral cavity. the patient’s health.

Historically, dentistry’s former “silo” by providing counseling on tobacco toring of diseases and disorders and the safe training approach has resulted in cessation and offering therapeutic use of medications (TABLE).10,11 isolated practitioners rather than fully recommendations to aid in quitting.9 Dentists and pharmacists also share integrated players in the interdisciplinary There is a great potential for responsibilities or have complementary health care team.5 Similarly, improvement in patient-centered care responsibilities related to patient care community pharmacists who practice with the development of new, closer and within the specifi c components of the in independent or chain stronger interprofessional collaborations care they each provide. These shared tend to be physically isolated from other among the various health care professionals. and complementary responsibilities professionals, limiting interprofessional The purpose of this article is to explore the provide excellent areas for potential interaction to fax, phone calls or other current relationship between dentists and collaboration. They could result in electronic means of .6 pharmacists and to propose new models improved and more effi cient patient care Interestingly, dentistry and pharmacy of interprofessional collaboration that with respect to medical and medication share a common patient care approach, target improvements in patient care. histories, , prevention as they both focus on the physical and management of and the body and are guided by evidence-based and Pharmacist: Complementary management and referral of patients. interventions.4 Discussions centered Roles and Responsibilities A patient’s medical and medication on patient cases between dentists The general responsibilities in the history, including and and pharmacists provide an excellent clinical practice of dentists and pharma- vaccinations, is very important to opportunity for collaboration. A cists may differ somewhat (TABLE),10,11 but both the dentist and the pharmacist crucial distinction between these two provide many opportunities for collabora- in the assessment of the patient. This disciplines lies in patients’ accessibility tion to improve patient care and enhance information assures recognition of to their services. While dentists are effi ciencies in providing care. The major problems that may need to be treated usually only available by appointment, responsibilities of dentists focus on the and the appropriateness of that the opposite is true of pharmacists. health of the oral cavity and the major may be needed or avoided. The dentist’s This is particularly signifi cant for those responsibilities of pharmacists focus on patient chart and the pharmacist’s patients who lack access to oral health the use of medications for overall health. patient-medication profi le will likely providers and thus seek community However, both professions have respon- complement each other, but are generally pharmacists for concerns pertaining sibilities for the overall improvement of a not a complete based to oral health.7,8 Pharmacists may patient’s health, diagnosis or recognition of on the limitations within those records also assist in oral health preventive disease and disorders, promotion of health, and the number of physicians, dentists services such as oral prevention prevention of disease, treatment and moni- and pharmacists that patients may see

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for their care. Dentists and pharmacists Dental Practice Pharmacy are likely at a similar disadvantage, depending upon their practice site and affi liation, in having little or no access to a patient’s full medical records and clinical laboratory studies and other tests and could therefore benefi t through FIGURE 1. First model of interprofessional collaboration: Dentist and pharmacist collaborate in the sharing of clinical information that close proximity. each has on a specifi c patient. Patients would need to be well-informed and would probably need to provide HIPAA the management of chronic pain could other products that may be needed in the consent for sharing of that information. be very useful in pain management, prevention or management of infections. Whether or not information from records the selection and use of Collaboration arrangements could is shared, the dentist and the pharmacist and referral for naloxone if needed. also involve referral and consultation can also consult each other on the use The prevention and treatment of between dentists and pharmacists for of medications in patients with allergies, infection is also a common and complex other problems. Patients may seek a contraindications or other conditions that clinical problem for dentists and pharmacist for concerns related to may be associated with adverse effects, pharmacists. The medical and medication pain,7,13 therefore, a pharmacist could drug interactions or other problems. history can be used to identify a patient refer a patient with an oral problem to a A clinical problem commonly addressed who may be at high risk for infection, at specifi c dentist (his or her collaborative by both dentists and pharmacists is the high risk for and therefore partner) for evaluation and possible care. management of pain due to oral conditions needs prophylaxis for a dental Dentists may refer patients to a pharmacist or procedures. The treatment of pain is procedure, has an that may for vaccinations, facemasks and gloves, as complicated by the need to provide relief affect antibiotic selection and/or has the mentioned above, in addition to oral care for mild to severe pain, but also being able need for one or more vaccinations. The products and smoking cessation products. to recognize and avoid the potential for development of resistance is always a Once additional regulations and guidelines drug abuse, addiction and diversion. The concern when considering which antibiotic are in place, dentists may also refer patients medical and medication history, as noted to use. A collaborative arrangement to pharmacists for naloxone, travel above, may be very useful in determining between dentists and pharmacists could medicine, self-administered hormonal if a patient is at risk for addiction or abuse address many of these issues. Sharing contraception and the ordering of routine but may also be limited if a patient goes information on medical and medication laboratory studies to monitor diseases.12 to a number of pharmacies for different histories is noted above. Dentists and A consultation may be appropriate for prescriptions. The duration of pain before pharmacists could pool their resources managing patients with diffi cult situations, and following a dental procedure is and develop a shared understanding such as those patients on anticoagulants or usually short term, but a small number of of up-to-date treatment guidelines for antithrombotic agents or with a bleeding patients in a dental practice may require endocarditis prevention, the treatment disorder who must undergo a dental chronic therapy for their dental condition. and prevention of other infections and procedure. Emergent medical situations Management of chronic pain is much more vaccinations. Current resistance patterns may occur in the dentist’s offi ce or in complex than the management of acute that have developed locally, regionally the pharmacy and may be more readily pain, requiring long-term follow-up for or nationally and are reported by health resolved if resources and expertise are effi cacy, abuse, addiction and adverse effects. care agencies and could also combined. For example, dentists’ offi ces Additionally, a state bill was recently passed be shared. Additionally, dentists could commonly have oxygen available for and guidelines are under development refer patients and staff to the pharmacist emergency use. Additionally, the dentist in California to allow a pharmacist to for evaluation and administration of and pharmacist may consult with each furnish naloxone for the prevention vaccinations.12 Patients could also other to discuss the appropriateness and treatment of opioid overdose. 12 be referred to the pharmacist for the of referring a patient to a , A dentist-pharmacist collaboration in purchase of any facemasks, gloves and emergency department or .

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Pharmacy

Dental Pharmacy Practice

Pharmacy Pharmacy Pharmacy Dental Practice

Dental Practice Pharmacy Dental Practice

FIGURE 2. Second model of interprofessional collaboration: Dental in FIGURE 3. Third model of interprofessional collaboration: Network of preferred collaborative agreements with multiple pharmacies. pharmacies and dental .

Interprofessional Practice Models pharmacy. The network of pharmacies to drug-drug interactions, drug-disease The following collaborative would become those that the dentist would interactions or medication allergies. interprofessional models have been preferentially refer patients to and would There are a number of factors developed with the goal of utilizing the call for consultation. Those pharmacies, in to consider in developing these above overlapping and complementary return, would preferentially refer patients to interprofessional collaborative practice roles and responsibilities of dentists that dental practice or other dental practices models. The fi rst major consideration will and pharmacists to enhance patient in which they had similar relationships. be the development of the agreements care. The major considerations used in A third model, the “in-network” model, or documents that describe the roles and developing these models include the would include a network of both dental responsibilities of each partner. In the physical proximity of the dental practice practices and pharmacies, which would beginning, these agreements should be and the pharmacy, as well as the nature of function very similarly to the second model informal and nonbinding, but should the populations of patients each serves. (FIGURE 3). The network of pharmacies provide specifi cs on potential interactions A strong interprofessional collaboration would become those that the dental and collaborations. These agreements may between a dental practice and a pharmacy practices preferentially refer patients to then evolve into more formal and binding could be developed if the two are in and would call for consultation. Those arrangements if deemed appropriate by all close proximity and provide care to a pharmacies in return would preferentially partners. This evolution may also include reasonable number of the same patients refer patients to those dental practices. The the development of protocols for patient (FIGURE 1). This could result in an dentist network and pharmacy network care and/or referral. It would also be very ongoing, highly interactive collaborative should place into effect a triage protocol important to monitor the progress of these practice model referring patients back by which to identify cases that require a arrangements, resolve any issues and make and forth and providing for consultation dentist’s expertise and classify the urgency improvements where needed. Holding among the dentists and pharmacists in of the situation. Then, the partnered periodic meetings among the partners each practice. Each professional could pharmacists will be able to correctly identify would be very benefi cial in monitoring and be available “on call” to assist in the and refer the appropriate cases to the enhancing the strength of the collaboration. care of patients from the other partner. dentist provider. Likewise, dental offi ces Input from patients could also be sought on A second model would involve a may rely on their partnered pharmacist the benefi ts and any shortcomings of the single dental practice that develops network to refer patients who would benefi t interprofessional collaboration. Given that interprofessional collaborative arrangements from comprehensive medication therapy patient care is the primary concern of each with a number of local pharmacies (FIGURE management and therapy counseling. professional, it is also important to recognize 2). This would be particularly useful in Furthermore, therapeutic recommendations that patients may want to receive care from areas where there are few shared patients could be made to the referring dentist when one partner, but not from the other partner between the dental practice and any specifi c questions regarding therapy arise secondary of any dentist-pharmacist interprofessional

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REFERENCES collaborative practice. Finally, these 1. Institute of Medicine. Health Professions Education: A 8. Priya S, Madan Kumar PD, Ramachandran S. Knowledge and models could also serve as examples to Quality. The National Academies Press, Washington, D.C. attitudes of pharmacists regarding oral health care and oral (2003). www.nap.edu/openbook.php?record_id=10681. products in Chennai city. Indian J Dent Res 2008;19:104–8. of interprofessional collaborative best- Accessed April 27, 2015. 9. Weinberg MA. Oral cancer risk factors and the pharmacist’s practice sites for the dental and pharmacy 2. Wilder RS, O’Donnell JA, Barry JM, Galli DM, Hakim role in intervention. www.uspharmacist.com/content/d/featured_ education and postgraduate training. FF, Holyfi eld LJ, Robbins MR. Is dentistry at risk? A case for articles/c/11583. Accessed April 15, 2015. interprofessional education. J Dent Educ 2008;72(11):1231–7. 10. American Dental Association. www.ada.org/en/about-the- A fundamental challenge of these 3. Oandasan I, Reeves S. Key elements for interprofessional ada/dentists-doctors-of-oral-health. Accessed April 10, 2015. interprofessional collaborative practice education. Part 1: The learner, the educator and the learning 11. American Association of Colleges of Pharmacy. www.aacp. models resides in the monetary costs for context. J Interprof Care 2005;(Suppl. 1): 21–38. org/resources/student/pharmacyforyou/Pages/roleofapharmacist. 4. MacEntee MI. Muted dental voices on interprofessional health aspx. Accessed April 10, 2015. their development and identifying the care teams. J Dent 2011; 39 (Suppl. 2): S34–40. doi:10.1016/j. 12. California State Board of Pharmacy. 2015 Law Book for specifi c groups that will be covering the jdent.2011.10.017. Pharmacy. www.pharmacy.ca.gov/laws_regs/lawbook.pdf. costs. While an ideal model would be one 5. DePaola DP. The Revitalization of U.S. Dental Education. J Dent Accessed April 10, 2015. Educ 2008;72(2 Suppl):28–42. 13. Cohen LA, Bonito AJ, Akin DR, Manski RJ, Macek MD, that places dentists and pharmacists within 6. Herrier R, Brownlee M, Hubbard S. Improving Edwards RR, Cornelius LJ. Role of pharmacists in consulting with the same physical location, this is not a Health Care Delivery Through Interprofessional Practice. the underserved regarding pain. J Am Pharm Assoc model that is feasible for the majority of J Am Pharm Assoc (2003) 2004;44:651–658. 2009;49:38–42. doi: 10.1331/JAPhA.2009.07149. doi:10.1331/1544345042467245. professionals. It is challenging to justify 7. Cohen LA. Enhancing pharmacists’ role as oral health advisors. THE CORRESPONDING AUTHOR, Cynthia Valle-Oseguera, PharmD, the added costs in salary that having a J Am Pharm Assoc 2013;53:316–321. doi: 10.1331/ can be reached at cvalleoseguera@pacifi c.edu. pharmacist in a general dentistry practice JAPhA.2013.12017. would accrue. However, formulating practice agreements between a dental offi ce and a pharmacy or pharmacists’ network would be a doable approach to begin active interprofessional collaboration among these professionals. Another challenge is that the creation of protocols and development of partnerships take time and it is important to remain invested in the process.

Conclusion As we seek to eradicate gaps in medical care, it is imperative that collaborations be fostered and developed among all health care professionals. With the implementation of a seamless process that facilitates the treatment of oral conditions by dentists and pharmacists in a patient- centered approach, it would be expected to see an increase in patient safety, patient satisfaction and overall patient well- being. This collaboration would provide a more comprehensive care approach to patients, where both professions are able to draw from each other’s expertise to provide optimal patient care. However, future studies need to be conducted on the implementation of the proposed models in order to determine the existence and the extent of these benefi ts. ■

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