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A Veritable Quandary?

One of the most common questions we hear from licensed dental healthcare professionals when considering the prospect of dropping their federal Drug Enforcement Agency (DEA) permit is “Can I do that?”

The answer is “Yes you can”.

Your professional license issued by the state in which you practice affords the ability to conduct patient care within the parameters set by law. This includes the ability to prescribe medications within the scope of those parameters including controlled substances – except for the requirement if you wish to prescribe same, you must obtain a federal permit from the US Drug Enforcement Administration to do so. Occasionally states may also require you obtain a state permit, but it is solely dependent on those states alone.

There may be matters of practicality. You are never under any mandate to prescribe controlled substances although certain privileges – such as the ability to administer sedation or anesthesia – will require the ability to procure anesthetic agents which are themselves controlled substances making the possession of a permit a necessity.

So, to reiterate: you are NEVER under any mandate, any requirement whatsoever to possess a federal DEA permit unless the scope of your practice requires itself. Beyond that, it is a choice.

We teach this in our state mandated safe opiate prescribing courses for dentists. In many ways, this is a benefit of practicing dentistry – even more so – it obviates the requirement for this continuing education not to mention the cost of the DEA permit. Check out our course offerings to find out more.

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NC Practitioner Compliance With CSRS

The home/welcome page of the NC Board of Dental Examiners has an interesting post copied from the NC Medical Board’s website. Not too unexpectedly, CSRS is flagging registrants who have been prescribing controlled substances but not reviewing a patient’s CSRS profile. In this post it states:

Administrators of the state-run North Carolina Controlled Substances Reporting System (NC CSRS) recently sent letters to some licensees who may not be checking patient prescription histories as required before prescribing certain medicines.

State law requires that prescribers review a patient’s 12-month prescription history in the NCCSRS before prescribing a Schedule II or Schedule III opioid. The requirement went into effect July 7. The full text of the law that mandates NC CSRS use can be read here. The NC DHHS letters inform prescribers that information about their possible noncompliance has been shared with the appropriate licensing board, which has prompted multiple licensees who believe they have been inappropriately flagged as noncompliant to reach out to NCMB. NCDHHS has provided a report to NCMB and the information is under review. No determinations have been made about how to use the reported information. NCMB is committed to working with NCDHHS to improve this process and will update licensees when it determines what action, if any, to take in response to data provided.

Licensees who believe they have been inappropriately flagged as noncompliant should email NCCSRS at Please note that the email address included in the NCDHHS letters mailed to prescribers includes a typo that causes messages to bounce back as undeliverable. Learn more about mandatory use of NC CSRS, including exemptions to the requirement, at

by NC Medical Board

Dentistry is way far behind other health care domains (medicine, pharmacy, etc) when it comes to adopting a true electronic health record and e-prescribing. Frankly there is no real motivation to do so beyond e-prescribing as compared to the medical domain due to ties with reimbursement. But what most dentists do not appreciate is that much of healthcare now exists in the digital realm and information is exchanged.  This means now we all leave a real digital footprint is – especially when it comes to prescribing controlled substances.  

Though we appreciate inquiries made through CSRS enables practitioners to find out about their patients, we might not appreciate that regulatory entities could gather the same information about us.  In fact, the reporting that can be made through reporting systems like CSRS can be quite robust including the ability to rank providers activities and to find outliers.  This could mean that practitioners whose controlled substance prescribing activities do not fall within certain criteria might otherwise be flagged for further inquiry.

We believe the message is very clear for NC dentists – CSRS will probably be providing similar information to the NCBDE.  So, bring yourself into compliance, and do so now.

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NC CSRS Gateway Integration De-mystified

In 2009 the Obama Administration championed the development of the HITECH Act.  Among its many ramifications were the development of “meaningful use” parameters intended to provide financial incentives through health care insurance reimbursement (Medicare, Medicaid) for health care entities to adopt technological advances to make health care more accessible and affordable.

The HITECH Act accomplished this through the elimination of commercial, economic, and technical barriers. The HITECH Act focuses on “interoperability,” meaning that policies, programs, and incentives must aim for EHR software and systems that can share information with other EHR software and systems.  The ability of electronic healthcare records (EHR) to exchange information is referred to as “information exchange” or simply “IE” – an example of which might be for enterprise entities to access state public health databases (vaccination records, etc) to update their EHRs with that data.

Meaningful use parameter such as IE have been integrated into enterprise medical EHR platforms within hospitals and their patient care networks.  However, since Dentistry does not have any significant reimbursement through Medicare there are no incentives for dental EHR platforms to adopt many of these parameters.

In 2017 the NC General Assembly passed the “Strengthen Opioid Misuse Prevention Act” or “STOP Act.” Portions of the Act went into effect immediately, others were to go into effect at later dates.  However, the time has now come for the  requirement that all prescribers of targeted substances  consult with the DHHS’s Controlled Substance Reporting System (CSRS).

On June 25,2021 the NC Board of Dental Examiners (NCBDE) issued an advisory that effective July 7, 2021 all NC dentists MUST consult the CSRS prior to prescribing a targeted substance and must make note of it in the patients dental record.

NC Dental Licensees – July 7th approaches!!!!  If you are a dentist who prescribes opioids in NC, know this date. The STOP Act, passed by the NC General Assembly in 2017, takes full effect on this date. As of July 7, you MUST query CSRS before prescribing any controlled substance, and you MUST note in the patient record that you have done so. The NCBDE is also more likely to begin to enforce the mandate of e-prescribing of controlled substances at this time. (See Mr Kurdy’s Blog post here)

by Sean Kurdys, Old Well Consulting

Apriss Health – the software vendor for NC CSRS – has provided some integrations to it’s API (application programming interface – or “the handshake”) that make accessing CSRS from within common medical EHR systems and often times it is seamlessly integrated.  This is facilitated by the fact there is one EHR platform – EPIC – which dominates the health care domain.  However, again, within popular dental EHR programs, there is no standardization and little if any interoperability.  This is further complicated by the fact that many states utilize differing prescription drug monitoring programs (PDMPs) aside from those offered by Apriss. Even more there is no clear dental EHR platform which dominates the market.  Therefore, there is no default integration for PDMP data.  

Anyone in Dentistry who has significant experience with NC CSRS will acknowledge that while it provides essential information, it is not necessarily efficient to use.  Fortunately for NC dentists however, as noted in the June 25, 2021 advisory, Apriss Health has developed a piece of software – known as gateway integration – that will integrate NC CSRS data into some of the more popular dental EHR programs.

The following dental EHR software programs are compatible with NC CSRS gateway integration:

  • All Carestream products
  • Dentrix
  • EasyDental
  • Henry Schein Medical (Dental?)
  • Medent
  • Open Dental
  • Patterson EagleSoft
  • Practiceworks
  • SoftDent
  • WinOMS

Dental practices can initiate the CSRS gateway integration by clicking this link and following the instructions listed.  If uncertain as to how to proceed, practices should consult their respective IT professionals for further advise and guidance.

There are a number of low tech strategies that can also be adopted such as the exporting of patient data from dental EHR schedules.  There is some formatting that is required to bulk query NC CSRS and the file must be in the proper format.  Please do not hesitate to contact us if you have any further questions.

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Analgesia & COVID Vaccination

NSAIDS May Impair Host Defenses

The preference for the use of non-opioid analgesics for pain should now be obvious.   However as the option of public COVID-19 vaccination is now widely available in many states, practitioners should be cautioned about the routine use of NSAIDS for pain relief where their treatment may overlap a patient’s vaccination window.(1)

NSAIDs inhibit cyclooxygenase (COX) which plays a critical role in the prostaglandin mediated inflammatory process.  The COX enzyme system exists as isoforms COX1 and COX2 with COX2 being pro-inflammatory.  COX2 is also responsible for optimal for antibody production from B-lymphocytes.

The implication is that both non-selective inhibitors (COX1/COX2) – like ibuprofen – and selective inhibitors (COX2) – like celecoxib – after infection or any vaccination may impair host defenses – and probably should be avoided in favor of acetaminophen.

1.   Bancos S, Bernard MP, Topham DJ, Phipps RP. Ibuprofen and other widely used non-steroidal anti-inflammatory drugs inhibit antibody production in human cells. Cell Immunol. 2009;258(1):18-28. doi: 10.1016/j.cellimm.2009.03.007. Epub 2009 Apr 5. PMID: 19345936; PMCID: PMC2693360.