Documenting medication use in adult dental patients: 1987-1991.

The authors surveyed 5,002 dental outpatients to determine the prevalence and patterns of drug use. They found that drug use increased significantly with age and that a significant number of patients took medications that had potential for adverse dental effects. Thus, dentists should be aware of patient medications and the effects those drugs have on dental treatment.     

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.     

Antidepressant use in psychiatry and medicine: importance for dental practice

BACKGROUND: Many dental patients receive antidepressant therapy. However, antidepressants taken with other drugs may increase the risk of complications that require special dental precautions and care. METHODS: The authors conducted a retrospective study of 1,800 randomly selected patient records and evaluated the prevalence of using antidepressants and other medications concurrently. They analyzed antidepressant intake relative to drug classification and mechanism of action, age, sex and associated potential for clinical complications such as xerostomia, orthostatic hypotension and interaction with vasoconstrictors. The potential for additive adverse effects between antidepressants and other medications also was analyzed. RESULTS: Three hundred eighty-one (21 percent) of the 1,800 patient records indicated that patients were being treated with 412 antidepressants. Female subjects out-numbered male subjects by an approximate 2.3:1 ratio. Selective serotonin reuptake inhibitors were most commonly prescribed, followed by tricyclic antidepressants, atypical and third-generation antidepressants, and monoamine oxidase inhibitors. Based on reported medication intake, almost 58 percent of subjects in the antidepressant group were receiving treatment with two or more medications that had the potential for producing xerostomia. Two hundred fifty-seven (67 percent) of the 381 records documented intake of an antidepressant or other medication with orthostatic hypotension potential. CONCLUSIONS: Three hundred eighty-one patients reported that they were receiving antidepressant therapy for psychiatric and other medical reasons. Potential adverse effects and interactions with other medications have direct implications for dental treatment. CLINICAL IMPLICATIONS: Patients receiving antidepressant therapy are at risk of developing xerostomia and orthostatic hypotension, as well as experiencing the adverse effects of interaction with vasoconstrictors. Dentists must take appropriate precautions in treating these patients.     

The effects of antihypertensive medication on dental treatment

Hypertension is a medical problem that impacts on health worldwide. A number of different medications are used to treat hypertension. These drugs can affect the mouth and perioral structures and impact upon dental management. It is therefore important that dentists are aware of the side-effects and relevant drug interactions that occur in patients on antihypertensive medication. Clinical Relevance: Dentists will encounter patients receiving antihypertensive therapy and should be aware of how these drugs impact upon dental treatment.     

Adverse drug interactions in dental practice: interactions associated with local anesthetics, sedatives and anxiolytics. Part IV of a series

BACKGROUND: This article is the fourth in a five-part series based on a 1998 International Association for Dental Research symposium entitled "Adverse Drug Interactions in Dentistry: Separating the Myths From the Facts." The symposium evaluated the significance of various drug interactions associated with dental therapeutics. METHODS: Local anesthesia and preoperative oral sedative/anxiolytic therapy often are indicated for routine oral surgery and restorative dentistry. The author conducted a literature review of the drug interactions associated with the use of local anesthetics and sedatives. The quality of the information used to document these interactions and the severity of the possible adverse outcome were assessed using a significance rating scale for dental drug interactions. RESULTS: Many of the frequently described drug interactions were found to be poorly documented in the dental and medical literature. Others were determined not to be relevant to current dental practice. The use of local anesthetics, sedatives or anxiolytic agents in combination with other central nervous system depressant agents or in combination with drugs that inhibit their metabolism was associated with a few serious adverse drug interactions or complications. CONCLUSIONS: The adverse drug interactions associated with the use of local anesthetics and oral sedative/anxiolytic agents in general practice vary in significance. An understanding of possible adverse drug interactions in dentistry may help practitioners avoid and prevent these complications.     

The psychopathology,medical management and dental implications of schizophrenia

BACKGROUND: Schizophrenia is a psychiatric illness characterized by thought disturbances, bizarre behaviors and cognitive impairments that may diminish a person's abilities in the areas of social relations, school or work and self-care. The onset of the disorder typically occurs between the late teens and mid-30s. Advanced dental disease is seen frequently in patients with schizophrenia for several reasons: the disease impairs these patients' ability to plan and perform oral hygiene procedures; some of the antipsychotic medications they take have adverse orofacial effects such as xerostomia; and these patients sometimes have limited access to treatment because of a paucity of financial resources and adequate number of dentists comfortable in providing care. The recent introduction of more effective medications has permitted the majority of patients to receive their psychiatric care from community-based providers rather than in the hospital. Consequently, dentists in the private sector also are being called on more frequently to care for these people. CONCLUSIONS. Dentists cognizant of the signs and symptoms of schizophrenia are likely to feel more secure in treating patients with schizophrenia and more confident when obtaining consultative advice from the patients' psychiatrists. Dentists usually can provide a full range of services to such patients, can enhance these patients' self-esteem and can contribute to the psychotherapeutic aspect of management. CLINICAL IMPLICATIONS: To effectively provide treatment to patients with schizophrenia, dentists must be familiar with the disease process so that they can communicate effectively with the patient, the treating psychiatrist and family members who serve as caregivers. In addition, dental treatment may need to be modified because of the patient's impaired ability to think logically, the local and systemic effects of psychiatric medications, and adverse interactions between these drugs and medications used in dentistry.     

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.     

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 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.     

Combining ibuprofen and acetaminophen for acute pain management after third-molar extractions: Translating clinical research to dental practice

BackgroundEffective and safe drug therapy for the management of acute postoperative pain has relied on orally administered analgesics such as ibuprofen, naproxen and acetaminophen, or N-acetyl-p-aminophenol (APAP), as well as combination formulations containing opioids such as hydrocodone with APAP. The combination of ibuprofen and APAP has been advocated in the last few years as an alternative therapy for postoperative pain management. The authors conducted a critical analysis to evaluate the scientific evidence for using the ibuprofen-APAP combination and propose clinical treatment recommendations for its use in managing acute postoperative pain in dentistry.Types of Studies ReviewedThe authors used quantitative evidence-based reviews published by the Cochrane Collaboration to determine the relative analgesic efficacy and safety of combining ibuprofen and APAP. They found additional articles by searching the Ovid MEDLINE, PubMed and http://ClinicalTrials.gov databases.ConclusionsThe results of the quantitative systematic reviews indicated that the ibuprofen-APAP combination may be a more effective analgesic, with fewer untoward effects, than are many of the currently available opioid-containing formulations. In addition, the authors found several randomized controlled trials that also indicated that the ibuprofen-APAP combination provided greater pain relief than did ibuprofen or APAP alone after third-molar extractions. The adverse effects associated with the combination were similar to those of the individual component drugs.Practical ImplicationsCombining ibuprofen with APAP provides dentists with an additional therapeutic strategy for managing acute postoperative dental pain. This combination has been reported to provide greater analgesia without significantly increasing the adverse effects that often are associated with opioid-containing analgesic combinations. When making stepwise recommendations for the management of acute postoperative dental pain, dentists should consider including ibuprofen-APAP combination therapy.     

Nociceptive trigeminal inhibition--tension suppression system: a method of preventing migraine and tension headaches

Dentists and physicians see countless patients suffering from various types of headaches. Various modes of therapy are used in an attempt to treat these patients. As a result of this study, it appears that a common factor to migraine and tension-type headaches may be chronic clenching. If this is the case, then dentists may treat headache patients more effectively than previously suspected through the use of a dental appliance.     

The pathophysiology, medical management and dental implications of adult attention-deficit/hyperactivity disorder

BACKGROUND: Few published reports in the dental literature have focused on adult attention-deficit/hyperactivity disorder (ADHD) and its dental implications. TYPES OF STUDIES REVIEWED: The authors conducted a MEDLINE search for the period 2000 through 2005 using the terms "adult" and "attention-deficit" to define ADHD's pathology, medical treatment and dental implications. RESULTS: ADHD is a developmental condition that affects slightly more than 4 percent of the adult U.S. population. Its symptoms include inattention, hyperactivity and impulsivity that can cause personal, social, occupational and leisure-time dysfunction. Medications used to treat the disorder include stimulants, selective noradrenergic uptake inhibitors and tricyclic antidepressants. CLINICAL IMPLICATIONS: The oral health of people with ADHD may be compromised by inattention and impulsivity that impair home care regimens and can lead to cigarette addiction, which may cause oral cancer and damage the periodontium, and excessive ingestion of caffeinated sugar-laden soft drinks that promote dental caries. To safely care for this patient population, dentists must be familiar with the stimulant and nonstimulant medications used to treat adult ADHD, because these drugs can cause adverse orofacial and systemic reactions and interact adversely with dental therapeutic agents.     

Lack of a scientific basis for routine discontinuation of oral anticoagulation therapy before dental treatment

BACKGROUND: There is a widespread belief among dental practitioners and physicians that oral anticoagulation therapy in which patients receive drugs such as warfarin sodium must be discontinued before dental treatment to prevent serious hemorrhagic complications, especially during and after surgical procedures. OVERVIEW: The authors examine the scientific basis for properly managing the dosage of anticoagulants for dental patients who are receiving anticoagulation therapy. The authors review the appropriate laboratory test values to which dentists should refer when evaluating for dental treatment patients who are receiving anticoagulation therapy. The authors also review clinical studies, published within the past five years, that focus on the frequency and degree of hemorrhagic and related complications among dental patients who are receiving anticoagulation therapy orally to prevent thromboembolic events. CONCLUSIONS AND CLINICAL IMPLICATIONS: The scientific literature does not support routine discontinuation of oral anticoagulation therapy for dental patients. Use of warfarin sodium as it relates to dental or oral surgical procedures has been well-studied. Some dental studies of antiplatelet therapy are consistent with the findings in warfarin sodium studies. Dental therapy for patients with medical conditions requiring anticoagulation or antiplatelet therapy must provide for potential excess bleeding. Routine discontinuation of these drugs before dental care, however, can place these patients at unnecessary medical risk. The coagulation status--based on the International Normalized Ratio--of patients who are taking these medications must be evaluated before invasive dental procedures are performed. Any changes in anticoagulant therapy must be undertaken in collaboration with the patient's prescribing physician.     

Differential pharmacology of drugs used for intravenous pre-medication

The differential effects of drugs used for intravenous pre-medication are reviewed using the results of controlled clinical trials in dental outpatients. The evaluation of clinical success requires experimental control of factors which can confound both the therapeutic and evaluation processes. The evaluation of drugs which are given primarily to alleviate anxiety requires that this effect be assessed by the patient's self-report rather than by the clinician's estimate of drug effect based on external manifestations. The results of the studies reviewed suggest that intravenous diazepam accomplishes the therapeutic objectives of anxiety relief, decreased pain perception, and amnesia. The addition of a narcotic, while reducing the diazepam dose, does not result in any greater effect, but does improve patient cooperation. It is concluded that diazepam, administered to clinical end-point, accomplishes most of the goals of intravenous pre-medication with minimal potential for adverse effects. The use of additional agents may improve patient cooperation, but this possible advantage must be weighed against the potential for increased systemic effects.     

Nociceptive trigeminal inhibition--tension suppression system: a method of preventing migraine and tension headaches

Dentists and physicians see countless patients suffering from various types of headaches. Various modes of therapy are used in an attempt to treat these patients. As a result of this study, it appears that a common factor to migraine and tension-type headaches may be chronic clenching. If this is the case, then dentists may be able to treat headache patients more effectively than previously suspected through the use of a dental appliance.