Adverse drug interactions in dental practice: interactions associated with vasoconstrictors. Part V of a series.

BACKGROUND: Adrenergic vasoconstrictors are commonly used by dentists to enhance the pain-relieving action of local anesthetics and to control local bleeding. Although normally considered safe for these applications, vasoconstrictors can participate in drug interactions that potentially are harmful to patients. METHODS: The faculty of a March 1998 symposium entitled "Adverse Drug Interactions in Dentistry: Separating the Myths From the Facts" extensively reviewed the literature on drug interactions. They then established a significance rating of alleged adverse drug interactions pertaining to dentistry, based on the quality of documentation and severity of effect. The author of this article focused on the adrenergic vasoconstrictors epinephrine and levonordefrin. RESULTS: Vasoconstrictor drug interactions involving tricyclic antidepressants, nonselective beta-adrenergic blocking drugs, certain general anesthetics and cocaine are well-documented in both humans and animals as having the potential for causing serious morbidity or death. Evidence for adverse interactions involving adrenergic neuronal blocking drugs, drugs with alpha-adrenergic blocking activity, local anesthetics and thyroid hormones is much less compelling, suggesting for the most part that clinically significant reactions may occur only when both the vasoconstrictor and the interacting drug are used in excessive doses. In the case of monoamine oxidase inhibitors, there is no credible evidence of a significant interaction with epinephrine or levonordefrin. CONCLUSIONS: Potentially serious adverse drug interactions involving adrenergic vasoconstrictors can occur in dental practice. In most circumstances, careful administration of small doses of vasoconstrictors and avoidance of gingival retraction cord containing epinephrine, coupled with monitoring of vita signs, will permit these drugs to be used with no risk or only minimally increased risk. Only in the case of cocaine intoxication must adrenergic vasoconstrictors be avoided completely. CLINICAL IMPLICATIONS: For optimal patient safety, dentists must recognize potential drug interactions involving adrenergic vasoconstrictors and modify their use of these agents accordingly.     

Adverse drug interactions in dental practice: interactions involving antibiotics. Part II of a series

BACKGROUND: The prudent use of antibiotics is an integral part of dental practice. While these agents generally are considered safe in the dental setting, their use can result in interactions that can lead to serious morbidity in dental patients. METHODS: The faculty of a symposium entitled "Adverse Drug Interactions in Dentistry: Separating the Myths From the Facts" did an extensive literature review on drug interactions. Through this, they were able to establish a significance rating of alleged adverse drug interactions as they relate to dentistry, based on their scientific documentation and severity of effect. The author of this article focused on antibiotics. RESULTS: Most of the reported drug interactions discussed in this article are well-documented by clinical studies. It is particularly important that dentists be aware of the potentially serious and life-threatening interactions of the antibiotics erythromycin, clarithromycin and metronidazole, and of the antifungal agents ketoconazole and itraconazole, with a host of other drugs whose metabolism is impaired by these antimicrobial agents. In contrast, the alleged ability of commonly employed antibiotics to reduce the effectiveness of oral contraceptive agents is not adequately supported by clinical research. It still is recommended, however, that clinicians discuss this possible interaction with their patients, as it might represent a relatively rare event that cannot be discerned in clinical trials. CONCLUSIONS: Potentially serious adverse drug interactions can occur between antimicrobial agents used in dental practice and other drugs patients are taking for a variety of medical conditions. CLINICAL IMPLICATIONS: It is important that dentists stay abreast of potential drug interactions involving antibiotics to avoid serious morbidity among their patients.     

Drug therapy for the pregnant dental patient

Providing needed dental treatment, managing oral infection, and controlling pain are essential functions of dentists for helping patients maintain overall health during pregnancy. Medications commonly required for dental care consist of local anesthetics and associated vasoconstrictors, centrally and peripherally acting analgesics, sedative and anxiolytic agents, and antibiotics. Therapeutic drugs routinely used in dental practice are selected because of their known safety and effectiveness. However, for a pregnant patient requiring dental care, the agents routinely prescribed should be reevaluated for potential risks to the mother and/or fetus. The decision to administer a specific drug requires that the benefits outweigh the potential risks of the drug therapy. This article reviews and updates the recommendations for using dental therapeutic agents, thereby enabling general practitioners to select the safest drugs when treating pregnant dental patients.     

Adverse drug reactions in dentistry

An adverse drug reaction (ADR) is an undesirable effect of a drug. ADRs are possible with any medication that is prescribed or administered in the dental office. While most pharmacological agents in use today have favourable drug profiles and are relatively safe, the prudent clinician must be aware of the potential ADRs that can occur and be prepared to manage any complications. Here we review the most commonly used agents in dentistry, namely local anaesthetics, sedatives, analgesics and antibiotics, and their ADRs and management.     

Geriatric alcoholism: pathophysiology and dental implications

BACKGROUND: The authors reviewed the clinical features, epidemiology, diagnosis, medical treatment, orofacial findings and dental treatment of geriatric patients with alcoholism. TYPES OF STUDIES REVIEWED: The authors conducted MEDLINE searches for the period 1995 through 2004 using the terms "alcoholism," "geriatric," "pathophysiology," "treatment" and "dentistry." They selected reports published in English in peer-reviewed journals for further review. RESULTS: Physiological changes associated with aging permit the harmful effects of drinking alcohol to arise at lower levels of consumption than in younger people. Excessive use of alcohol exacerbates the medical and emotional problems associated with aging and predisposes the person to adverse drug reactions with medications controlling these illnesses. CLINICAL IMPLICATIONS: The incidence of dental disease in this population is extensive because of diminished salivary flow and a disinterest in performing appropriate oral hygiene techniques. Concurrent abuse of tobacco products worsens dental disease and heightens the risk of developing oral cancer. Identification of patients who abuse alcohol, a cancer-screening examination, preventive dental education, and use of saliva substitutes and anticaries agents are indicated. Clinicians must take precautions when performing surgery and when prescribing or administering analgesics, antibiotics or sedative agents that are likely to have an adverse interaction with alcohol.     

Pharmacotherapy in the geriatric population

The geriatric population constitutes the largest group of consumers of medications in this country. Changes in the pharmacokinetic response to medications of this population are less predictable than in younger age groups, thereby resulting in adverse reactions and drug interactions in multidrug users. Dentists need to be aware of these changes as well as alterations in therapeutic responses to the medications most commonly used in dental treatment: sedatives, local anesthetics, analgesics, and antibiotics.     

An emphasis on the wide usage and important role of local anesthesia in dentistry: A strategic review

Local anesthesia forms the major part of pain-control techniques in dentistry. The prevention and elimination of pain during dental treatment has benefited patients, their doctors and dental hygienists, enabling the dental profession to make tremendous therapeutic advances that would otherwise have been impossible. Introduced in the late 1940s, the amide local anesthetics represent the most used drugs in dentistry. Local anesthetics also represent the safest and most effective drugs in all of medicine for the prevention and management of pain. They are also accompanied by various adverse effects which should be well known and be able to be controlled by the clinician. The article reviews the types of agents used as local anesthetics and their effects on the human body.     

Drug interactions in dentistry: the importance of knowing your CYPs

BACKGROUND. The hepatic and intestinal cytochrome, or CY, P450 enzyme system is responsible for the biotransformation of a multitude of drugs. Certain medications used in dentistry can act as substrates, inducers or inhibitors of this system. METHODS. The authors conducted a MEDLINE search of articles appearing between 1976 and the present using the keywords "drug interactions" and "cytochrome P450," and reviewed reports involving dental therapeutic agents using PubMed links from an Indiana University CYP450 drug interaction table on the World Wide Web. RESULTS. The antibiotics erythromycin and clarithromycin are potent inhibitors of CYP3A4 and can increase blood levels and toxicity of CYP3A4 substrates. Likewise, quinolone antibiotics such as ciprofloxacin inhibit the metabolism of CYP1A2 substrates. Other dental therapeutic agents are substrates for CYP2C9 (celecoxib, ibuprofen and naproxen), CYP2D6 (codeine and tramadol), CYP3A4 (methylprednisolone) and CYP2E1 (acetaminophen). Because codeine and tramadol are prodrugs, inhibition of their metabolism can lead to a diminution of their analgesic effects. While inducers of acetaminophen metabolism, including alcohol, theoretically can increase the proportion of it that is biotransformed into a potentially hepatotoxic metabolite, recent research suggests that concomitant alcohol intake does not increase the hepatotoxic potential of therapeutic doses of acetaminophen. CONCLUSIONS: A number of clinically significant drug interactions can arise with dental therapeutic agents that act as substrates or inhibitors of the CYP450 system. Clinical Implications. As polypharmacy continues to increase, the likelihood of adverse drug interactions in dentistry will increase as well. Ensuring that patients' medical histories are up to date and acquiring knowledge of the various substrates, inducers and inhibitors of the CYP450 system will help practitioners avoid potentially serious adverse drug interactions.     

Bipolar I disorder: psychopathology,medical management and dental implications

BACKGROUND: The authors review the clinical features, epidemiology, pathophysiology, medical management, dental findings and dental management of patients who have bipolar I disorder, or BD, previously known as manic-depressive disorder. TYPES OF STUDIES REVIEWED: The authors conducted a MEDLINE search for the period 1995 through 2001 using the key terms "bipolar disorder," "epidemiology," "pathophysiology," "treatment" and "dentistry." The articles they selected for further review included those published in English in peer-reviewed journals; they gave preference to articles reporting randomized, controlled trials. RESULTS: BD is a psychiatric illness characterized by extreme mood swings. Mania is accompanied by euphoria, grandiosity, racing thoughts and lack of insight. Depression is characterized by marked sadness or loss of interest or pleasure in daily activities. The unpredictable mood swings can distress the person, can impair social function and quality of life and are associated with a significant increase in the risk for substance abuse and suicide. BD is common in the United States, with a lifetime prevalence rate of 1.6 percent and recurrence rate of more than 50 percent. CLINICAL IMPLICATIONS: The prevalence of dental disease usually is extensive because of poor oral hygiene and medication-induced xerostomia. Preventive dental education, saliva substitutes and anticaries agents are indicated. To avoid adverse drug interactions with the usually prescribed psychiatric medications, special precautions should be taken when administering certain antibiotics, analgesics and sedatives.     

A medical crisis management simulation activity for pediatric dental residents and assistants

Dentists are expected to deliver safe and pain-free dental procedures after they graduate from dental school. This includes using local anesthetics and sedative drugs that may be associated with side effects and complications that can lead to crisis situations. This study postulated that teaching medical crisis management to dental residents and assistants using human patient simulation (HPS) would improve their confidence in managing crisis situations in the real world. Four medical crisis scenarios were designed and programmed into a pediatric simulator. The scenarios included anaphylaxis, laryngospasm during procedural sedation, sedative medication overdose, and multiple drug interaction with cardiac arrhythmia. The simulation room was outfitted with an authentic dental operatory and emergency equipment to enhance the realism. One first-or second-year pediatric dentistry resident and a staff dental assistant were assigned as a team to participate in each ten-minute scenario followed by a debriefing session. At the end of the sessions, the participants completed an anonymous survey regarding the simulation experience. There were a total of twenty-four participants, 91.7 percent of whom felt that HPS was a good tool for learning medical crisis and that they will be more confident in managing a similar situation in the dental office after this experience. A majority of the participants felt that using HPS as a tool to teach crisis management is an acceptable and valuable technique to help improve their confidence in managing crisis situations that may occur in dental offices.     

Recent developments in local anesthesia and oral sedation

This article reviews 3 recent developments in anxiety and pain control with significant potential for altering dental practice. First is the introduction of articaine hydrochloride as an injectable local anesthetic. Although articaine is an amide, its unique structure allows the drug to be quickly metabolized, reducing toxicity associated with repeated injections over time. The second development is the formulation of a lidocaine and prilocaine dental gel for topical anesthesia of the periodontal pocket. This product may significantly reduce the need for anesthetic injections during scaling and root planing. Finally, the use of triazolam as an oral sedative/anxiolytic is reviewed. The recent administration of triazolam in multiple doses has extended the availability of anxiety control to many dental patients, but unknowns about the safety of the technique as practiced by some dentists remains a concern.     

Local anesthetics in dentistry

The purpose of the present paper is to carry out a review of the literature on local anesthetics (LAs), which are the most commonly used drugs in dentistry. Thanks to their improvement over the last few years, they have constituted an enormous advance in both odontological treatment -- improving the dental operation in a determinant manner, and the comfort of the patient during these procedures. Furthermore, the addition of a blood vessel constrictor to these local anesthetics has meant that a lower dose of anesthetic can be used, which at the same time acts for longer, providing better conditions for both the patient and dentist. In addition, a study is made of the possible drug interactions, contraindications etc. of the different components in the anesthetic solution, and likewise the possible allergic hypersensitive reactions which can take place and which must be taken closely into consideration when used in the oral cavity.     

Alcohol abuse and dependence: psychopathology,medical management and dental implications

BACKGROUND: The authors review the clinical features, epidemiology, pathophysiology, medical management, dental findings and dental treatment of patients with alcoholism. LITERATURE REVIEWED: The authors conducted a MEDLINE search for 1995 through 2001 using the key terms of alcoholism, epidemiology, pathophysiology, treatment and dentistry. Reports selected for further review included those published in English in peer-reviewed journals. The authors gave preference to articles reporting randomized, controlled trials. CONCLUSIONS: Alcoholism is a chronic and progressive psychiatric illness that afflicts more than 14 million Americans. It is characterized by a loss of control over the use of alcohol, resulting in impaired social functioning, and the consequent development of medical illnesses. The disease arises in genetically vulnerable people when they are overwhelmed by their cravings for the alcohol-associated euphoria that results from the actions of several neurotransmitter systems in the brain's pleasure center. New medications to counteract alcohol-induced neurotransmission imbalance may assist patients in reducing their craving. CLINICAL IMPLICATIONS: The prevalence of dental disease usually is extensive because of a disinterest in performing appropriate oral hygiene techniques and diminished salivary flow. Concurrent abuse of tobacco products worsens dental disease and heightens the risk of developing oral cancer. Identification of the alcohol-abusing patient, a cancer-screening examination, preventive dental education, and use of saliva substitutes and anticaries agents are indicated. Special precautions must be taken when performing surgery and when prescribing or administering analgesics, antibiotics or sedative agents that are likely to have an adverse interaction with alcohol or psychiatric medications.     

Polypharmacy and dentistry: I. Introduction and interactions with local anaesthetics and sedative drugs

This series of two papers considers the effects of drug interactions in dentistry. In this first paper, the principles of drug interactions will be described. In addition, interactions with drugs used in local anaesthesia and sedation will be discussed. The second paper will concentrate on interactions with analgesics and antimicrobials prescribed in dental practice.     

Local anesthesia: advances in agents and techniques

The improvements in agents and techniques for local anesthesia are possibly the most important advances in dental science to have occurred in the past 100 years. The agents currently available in dentistry have most of the characteristics of an ideal local anesthetic. Today's anesthetics can be administered with minimal irritation and little concern for stimulating allergic reactions. A variety of agents are available that provide rapid onset of surgical anesthesia with adequate duration. This article provides a brief review of the local anesthetic agents, formulations, and techniques used in dentistry with special emphasis on newly introduced agents and procedures.     

Adverse drug interactions in dental practice: interactions associated with analgesics, Part III in a series

BACKGROUND: Numerous reports of drug interactions exist, yet not all are valid in or pertinent to dentistry. This article provides an overview of drug interactions with analgesics and identifies those that are clinically relevant. METHODS: The author reviewed reports of drug interactions involving nonsteroidal anti-inflammatory drugs, or NSAIDs (including aspirin), acetaminophen and opioids to determine the interactions' validity and clinical relevance. Consistent with the practice followed in other articles in this series, the author determined the significance of the proposed interaction by gauging its reported severity and the quality of the documentation. RESULTS AND CONCLUSIONS: NSAIDs should not be taken by patients taking high-dose methotrexate, anticoagulants or alcohol. They should be avoided in elderly or renally impaired patients taking digoxin, and avoided over the long term in those taking other NSAIDs. It is possible that NSAIDs should not be given to patients taking lithium, but future studies should be conducted to confirm this. Use of NSAIDs likely is appropriate in the short term with patients taking antihypertensives, unless they have severe congestive heart disease. Aspirin should not be given to patients taking oral hypoglycemics, valproic acid or carbonic anhydrase inhibitors. Acetaminophen may be given in the short term to any patient with a healthy liver, but it should not be given to a patient who has stopped drinking alcohol after chronic intake. Opioids should not be combined with alcohol, and meperidine must be avoided in the patient who has taken monoamine oxidase inhibitors in the previous 14 days. CLINICAL IMPLICATIONS: Drug interactions with analgesics are often reported, but only a small number have clinical relevance in dentistry. Awareness of the significance of these interactions will allow dentists to prescribe analgesics optimally and minimize the potential for adverse reactions.     

Demystifying medical complexities

Although dentists often fear treating medically complex patients, in many cases this fear may be based not on scientific facts but rather on a "mythology" of the dangers of dentistry. Dentistry is a remarkably safe profession, even for most medically complex patients. The myths of endocarditis, artificial joint infections, local anesthetics and vasoconstrictors, dental surgery in anticoagulated patients and patients on antiplatelet drugs, and antibiotic interference with oral contraceptives are discussed. Although dental treatment is not usually a risk factor for endocarditis, practitioners should consult the 1997 American Heart Association statement for recommendations for endocarditis prevention. Most artificial joint patients should not receive antibiotic prophylaxis. Local anesthetics and vasoconstrictors can be used safely in most medically complex patients. Neither continuous anticoagulation nor antiplatelet medications should be withdrawn for dental surgery. Scientific studies have failed to document an interaction between antibiotics used in dentistry and oral contraceptives.