The Prescription Pad and the Dental Office

The number of individuals over the age of 65 is growing, comprising approximately 14% of the United States population.¹ Many of these older Americans are on consistent monthly prescription medication regimens. As the launch of the full Medicare Part D benefit program for seniors and individuals with disabilities increases their access to drugs, the number and types of drugs that people are taking will most likely increase (Table 1). With the use of prescription medications on the rise, dental professionals need to ensure that their patients’ health histories are consistently updated, especially the medication history, and that they are knowledgeable on the oral implications of the most commonly prescribed medications.

DRUG EFFECTS ON ORAL CARE

A major consideration when planning oral care is the patient’s ability to tolerate treatment procedures. The health history is evaluated for risks in providing oral care and vital sign values are considered when assessing risk.² When the medication profile is investigated, several factors are important, including the reason the drug is being taken, the effects of the drug, potential side effects that may influence the oral care plan, the degree of control of the medical condition, and potential interactions between the drug or systemic conditions and the agents planned for use in the treatment plan.

CARDIOVASCULAR AGENTS

The most commonly prescribed drug in 2006 was Lipitor^®*, the brand name for atorvastatin calcium, which is used to reduce cholesterol.³ Cholesterol lowering medications continue to be among the fastest growing drug classes dispensed by pharmacies. The introduction of the generic simvastatin Zocor^®** will likely influence the list of the most widely prescribed anti-cholesterol products in 2008 2009. Lipitor, which is part of the drug group referred to as statins, reduces harmful serum LDL levels (bad cholesterol) and triglycerides. It also reduces the risk for myocardial infarction and angina in those who exhibit risk factors for coronary artery disease, such as hypertension, smoking, and low HDL levels (good cholesterol). It is approved to reduce the risk of stroke. High serum cholesterol levels lead to the formation of atherosclerotic plaques within the lumen of blood vessel walls. Atherosclerosis reduces the ability of the vessel to dilate. Normal physiologic mechanisms that take over in order to cause vasodilation may not be able to overcome the damage. When the blood vessel becomes narrowed and adequate amounts of oxygenated blood cannot reach the tissues in the heart, ischemia occurs—causing pain or pressure in the chest (angina).⁴ Lipitor is prescribed for those who have experienced cardiac events or those with high levels of serum cholesterol that may lead to a cardiac event. Statin anti-cholesterol drugs are well tolerated with few side effects that affect oral care. Myalgia (muscle soreness) may indicate a need to make adjustments in patient positioning in the dental chair or to schedule shorter appointments. Dental drug interactions with all agents in the statin classification include erythromycin, clarithromycin, and the azole antifungal agents (ketoconazole, fluconazole, itraconazole). Concurrent use of the above anti-infective drugs can lead to reduced liver metabolism of the statin, resulting in increased blood levels of the statin and toxicity.

Toprol XL^®*** is a selective beta-1 blocking anti-hypertensive agent prescribed to reduce blood pressure. Blocking the beta-1 receptor results in lowering the heart rate, which promotes vasodilation, thereby reducing blood pressure. When local anesthesia is indicated, selective beta blockers are much safer than older nonselective beta blockers (propranolol) because they are less likely to interact with vasoconstrictors in local anesthetic agents. Dental drug interactions include cyclooxygenase inhibitors (COX inhibitors like ibuprofen and naproxen), which can reduce antihypertensive effects of Toprol XL. Norvasc^®* (amlodipine besylate) is an antihypertensive agent that is a calcium channel blocker. It works by inhibiting blood vessel contractility, promoting vasodilation, and thus reducing blood pressure. It reduces spasm in coronary arteries, promotes vasodilation, and is also used to prevent angina. Gingival hyperplasia, associated with other agents in this class, is uncommon with Norvasc. Oral biofilm removal does not eliminate the development of gingival hyperplasia, but may slow the process. Poor oral hygiene increases the risk for developing gingival hyperplasia.⁴ There is one case report describing oral ulcerations associated with calcium channel blockers.⁵ Inhibition of platelet function is possible with drugs in this class and increased bleeding should be monitored during invasive procedures.

CLINICAL IMPLICATIONS. The following are considerations for treating those with cardiovascular disease:

1. Determine the degree of disease control. The recent history of cardiac events will determine if the medical therapy has stabilized the condition. The functional capacity should meet a four metabolic equivalent⁶ (see Table 2), which is the terminology used to measure functional capacity. The American College of Cardiology and the American Heart Association suggest that the evaluation of functional capacity is a depictor of cardiac risk during any type of treatment. The organizations define the minimum safe level of functional capacity for receiving noncardiac surgery or superficial procedures (such as periodontal debridement, restorative dentistry) as four metabolic equivalents. This equates to the ability to climb a flight of stairs, walk up a hill, or run a short distance.⁷ Cardiac risks in association with oral care procedures are increased when the patient is unable to meet a four metabolic equivalent demand during normal daily activities.⁸

2. Vital signs should be monitored at each appointment when cardiovascular disease exists. The current recommendation by the American Dental Association to monitor vital signs on an annual basis as a screening measure for all dental patients is intended to identify undiagnosed hypertension.⁹

3. If blood pressure values are ?180/110, dental hygiene procedures should be delayed and the patient should be referred for a medical evaluation.

4. Vasoconstrictors should be used with caution and in low concentrations. For patients taking a nonselective beta blocker, limit epinephrine to two cartridges or less of 1:100,000 or four or less cartridges of 1:200,000.¹⁰

5. A stress reduction protocol should be considered for anxious patients (anti-anxiety agents, nitrous oxide, pain control, etc). Anxiety can increase the heart rate, thereby increasing the requirements for more oxygenated blood to supply cardiac muscle needs, which can elevate the risk for angina or myocardial infarction. Equipment for oxygen administration should be easily available.
*Pfizer Inc, New York

**Merck & Co Inc, Whitehouse Station, NJ
***AstraZeneca, Wilmington, Del

ANALGESICS

The second and sixth most frequently prescribed drugs in 2006 were for a generic painreliever combination product—hydrocodone with acetaminophen. This drug combination is marketed by a variety of pharmaceutical companies, hence the combination appears twice on the list of most commonly prescribed drugs. When a medical professional writes a prescription and specifies that a generic substitution can be made, the dispensing pharmacy selects which product to fill the prescription. The generic combination of hydrocodone/acetaminophen is commonly prescribed to relieve oral pain. This narcotic component (hydrocodone) makes it a schedule III drug and carries the risk of addiction, emphasizing the need to prescribe the drug for short time periods. ¹¹ Hydrocodone acts by binding with opioid receptors in the central nervous system, whereas acetaminophen inhibits the release of prostaglandins in the central nervous system. The mechanism for acetaminophen was unknown for many years and has only recently been understood.¹¹

Clinical implications.

1. When hydrocodone/ acetaminophen is reported on the health history, determine why the drug is being taken and for how long it has been used. Consider the impact on treatment procedures, such as patient positioning (chronic back pain).

2. Dental prescribers should use nonhabit forming agents for dental pain (COX inhibitors are effective for oral pain). Removing the cause of the inflammation will reduce oral pain profoundly in most cases.¹¹

ANTIBACTERIAL AGENTS

Amoxicillin is in the penicillin class of drugs and is widely used for oral infection. It is the drug of choice for antibiotic prophylaxis in the nonallergic patient. Amoxicillin is indicated for infection in the eye, ear, nose, throat, respiratory tract, and for skin structure infection. When prescribed by medical providers, the indication is often for respiratory infection. In this instance, the risk for contagious disease transmission to oral health personnel must be considered before initiating treatment.

Clinical implications.

1. To avoid the risk for operator infection, the indication for taking amoxicillin must be determined and the relevance to withholding oral procedures considered. Monitoring body temperature may provide a clue to determine the degree of infection.

2. Extrinsic staining is reported with a variety of antibacterial agents, including black hairy tongue and enamel staining.¹¹

3. Antibiotic-associated candidiasis can develop when an antibiotic is taken for several weeks. Monitor for signs of oral fungal infection.

4. If amoxicillin is taken for antibiotic prophylaxis prior to oral care, the dose and administration time should be recorded in the treatment record to verify compliance.

THYROID DISEASE

When hypothyroidism develops, thyroid hormone replacement therapy (HRT), such as Synthroid, is prescribed. If HRT is successful in controlling the condition, there is no contraindication to providing oral health care. The therapeutic index is narrow for this agent and overdose, leading to toxic thyroid storm, is a major risk factor. Uncontrolled hyperthyroidism in a situation of excess stress, such as fear or pain during a dental appointment, can lead to an emergency known as “toxic thyroid storm.” Blood levels should be monitored regularly by the prescribing physician to identify characteristics for hyperthyroidism, which signify an overdose situation.

Clinical implications.

1. Monitoring vital signs may identify when Synthroid levels have induced hyperthyroidism. Elevated blood pressure (>160/100) and elevated body temperature (>99°) are clues.^4,11

2. There is a weak interaction between thyroid hormone and vasoconstrictors; low concentrations are recommended (1:100,000).¹²

GASTRIC ACIDITY

Nexium^®* (esomeprazole) reduces the formation of gastric acids and is used for various gastrointestinal (GI) disorders (gastric reflux, chronic acidity, peptic ulcer disease). When the drug controls the symptoms of the indicated condition, there is no contraindication for oral care.

Clinical implications.

1. GI acid disorders may contribute to the development of oral effects from acids that enter the oral cavity, including erosion of the lingual aspects of teeth.

2. Rinsing with sodium bicarbonate mixed with water after the reflux event may increase the pH in the mouth and diminish the harmful effects.

3. Toothbrushing should be delayed for 1 hour after reflux to reduce removal of enamel. Fluoride products should be used daily and inoffice applications of fluoride should be considered.

4. Patients with reflux disease may request a semisupine position as the supine position promotes reflux.

5. Acid reducing drugs may reduce the absorption of drugs that require an acidic environment (penicillin, doxycycline). Patients should be advised to take the drugs 2 hours apart.

6. COX inhibitors, such as aspirin and nonsteroidal anti-inflammatory drugs (ibuprofen, naproxen) are contraindicated in many GI disorders (peptic ulcers, gastroesophageal reflux). This is because the decreased prostaglandins synthesis caused by COX inhibitors increases gastric acid secretion and decreases the secretion of protective gastric mucin.

*AstraZeneca, Wilmington, Del

**Forest Laboratories Inc, New York

DEPRESSION

Psychotherapeutic drugs are prescribed for a variety of indications (depression, mania, anxiety disorder, chronic pain). Lexapro** (escitalopram) is in the selective serotonin reuptake inhibitor (SSRI) class and suppresses the re-uptake of serotonin in the brain, allowing the neurotransmitter to be available for receptor binding, leading to mood elevation. Many elderly people take drugs in this therapeutic category. SSRIs are also prescribed during recovery from substance abuse. Lexapro is designed to boost the chemicals in the brain that elevate the mood, but some patients have less successful results. Recently the Food and Drug Administration reported warnings regarding an increased risk for suicide in young people taking SSRI agents. Safety in the pediatric population has not been established for Lexapro.

Clinical implications.

1. The reason for taking the drug should be investigated and the ability to tolerate the stress of oral care determined.

2. Xerostomia is common with long-term use (>1 week) and oral tissues should be examined for xerostomia-related disease (caries, candidiasis). Xylitol gum can be recommended to increase salivation and provide antibacterial effects (6 grams chewed three to four times daily).¹³

3. The potential for drowsiness and lack of attention to self-care (or traumatic self-care) exists.

4. There is a risk for a drug interaction between SSRIs and tramadol or oxycodone that can increase the effects of SSRIs, leading to serotonin syndrome (a variety of toxic effects including tachycardia, hypertension and, in some cases, death) and seizure.

BRONCHIAL THERAPY

Bronchodilators, such as albuterol, are used as rescue inhalation products to reverse bronchoconstriction quickly. It is commonly prescribed as part of medical therapy for asthma, obstructive pulmonary disease, and emphysema. Other agents to reduce symptoms of bronchial disease are often used concurrently with albuterol (corticosteroids and agents to decrease mucoid secretions in the airway). Clinical implications. Airway obstruction is the main issue of concern for bronchial disorders.

1. When albuterol is reported on the medication history, the drug should be brought to each appointment.

2. The respiratory rate and qualities should be monitored each appointment when respiratory disease is reported. Wheezing or noise during exhalation indicates uncontrolled disease. Overuse can lead to an increased risk for status asthmaticus. Symptomatic patients may need to be referred for medical evaluation and treatment delayed until control is established.

3. Albuterol is administered by inhalation and may be used several times daily. This leads to dryness of oral tissues and thick biofilm deposits. Self-care efficiency should be monitored.

4. Since albuterol is a sympathomimetic agent, tachycardia and elevated blood pressure are reported with this drug.¹¹ Vital signs should be monitored.

SUMMARY

A thorough review of the health history is essential to reduce the risk for medical emergencies during oral treatment. Both drug effects and the medical conditions they treat can influence provision of oral care. Determining the degree of disease control and investigating the potential drug effects and interactions are essential for effective patient management.

REFERENCES

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13. Milgrom P, Ly KA, Roberts MC, Rothen M, Mueller G, Yamaguchi DK. Mutans streptococci dose response to xylitol chewing gum. J Dent Res. 2006;85:177-181.

From Dimensions of Dental Hygiene. April 2008;6(4): 18-21.