Herbal supplements. Any relevancy to dental practice?

The increasing popularity of herbal supplements demands that dentists be more knowledgeable about the effects these supplements have on oral health and treatments. Based on the medical literature, at least some of the popular products appear to have the potential to elicit oral manifestations and adverse interactions with dental drugs. These effects seem to be associated primarily with antiplatelet, sedative and hepatotoxic properties of the herbs. An understanding of the effects of herbal supplements would allow dentists to provide improved dental care and to educate patients taking these products.     

Geriatric pharmacology for the dentist. An overview

The information presented in this article suggests that the drug responses of the elderly may be greater than those in the young or essentially the same. We have presented evidence that the pharmacokinetics in the elderly would probably tend toward prolonging the half-life and delaying the clearance of many drugs. Pharmacodynamic changes are more ambiguous, increasing sensitivity to some drugs and decreasing sensitivity to others. Compliance errors, from whatever cause, lead to unpredictable intake of drugs. Psychosocioeconomic factors contribute to compliance errors and no doubt also lead to increased intake of combination of drugs. Multiple diseases are common among the elderly, but it is not clear how disease states, per se, affect drug responses unless the specifically diseased organ is focally important in the handling of drugs. Alterations in perception of pain and in reflex and immune competence will produce changes in all directions. Use of multiple drugs almost certainly will create an environment favorable to drug interactions and adverse reactions. What is the dentist to do with these conflicting effects of aging in drug therapy? There are a few, and only a few, rules that can be said to have a solid basis in fact. Elderly patients seem to be more sensitive to the depressant effects of drugs. It is wise, therefore, to reduce the dosage of such drugs as the benzodiazepines, general anesthetics, analgesics, and sedative-hypnotics in the elderly. Old people are apparently more sensitive to certain drugs, for example, the neuromuscular blocking drugs. It would be wise to reduce the dosage of these for the older patient. The geriatric person appears to be less sensitive to pain; it would be wise to prescribe analgesics for such patients in lower doses. Elderly patients are known to have lost some of their reflex ability to maintain homeostasis. This should be taken into consideration when drugs that affect blood pressure, heart rate, and smooth muscle tone are used. Elderly patients are almost certain to be taking multiple medications. Drug interactions, as well as adverse drug reactions (which are exaggerated in the elderly), are likely to occur in this polypharmaceutical setting. It is critical that the dentist be continually informed of the pharmacologic status of each patient and be aware of the likelihood of interactions between drugs prescribed by the dentist, drugs-prescribed by the physician, and drugs that are self-administered.     

Migraine drug therapy: dental implications

Triptan drugs continue to constitute the major pharmacotherapeutic interventional agents for migraine therapy. Interactions of dental drugs with migraine medications are limited, but their seriousness dictates that dentists be aware of the use of ergot alkaloids, triptans, or other migraine drugs. While many migraine sufferers avoid dental therapy dur ing migraine attacks, the practitioner who is treating a patient who has taken migraine medications must carefully monitor the cardiovascular status of the patient, which may affect the use of vasoconstrictors. Macrolide antibiotics and azole antifungals represent additional drug groups that are prescribed by dentists but which may potentiate the adverse effects of migraine drugs. Migraine patients prefer agents that offer rapid onset of relief and total relief within a couple hours of drug administration; they also prefer therapy that prevents recurrences and does not require "rescue" medications, and, of course, a lack of adverse effects and interactions with other medications. Currently, no single drug or class of drugs offers this ideal combination of actions in all 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.     

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.     

Complementary and alternative medicine: impact on dentistry

Complementary and alternative medicine (CAM) represent a group of diverse medical and health care systems, practices, and products that are not considered to be part of conventional medicine. Biofeedback, acupuncture, herbal medication, massage, bioelectromagnetic therapy, meditation, and music therapy are examples of CAM treatments. Some dentists in the United States have used some of these treatments and products in their practices. Complementary medicines include herbal remedies, homeopathic medicines, and essential oils. There has been an increase in the use of herbal medicines in the US over the last 15-20 years. There is a public belief that these medicines are safe because they are made from natural sources. However, some of these products have associated adverse effects including toxicity and drug interactions. The health history taken by the dentist should include questions regarding the taking of herbal and over-the-counter medications. The dentist needs to be informed regarding the herbal and over-the-counter products that may impact the delivery of safe and effective dental treatment. In addition, the use of CAM treatments in dentistry should be based on evidence of effectiveness and safety as demonstrated in randomized clinical trials.     

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.     

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.     

Vitamin and mineral supplements: Friend or foe when combined with medications?

Background.Given the prevalence of vitamin and mineral supplement use among consumers and the potential for vitamin- and mineral-drug interactions, as well as oral and systemic adverse effects of excess consumption, oral health care providers (OHCPs) should ask all patients about their use. The challenges for OHCPs are how to recognize oral and systemic manifestations of these interactions and how to safely manage the care of these patients while avoiding potential interactions.Methods.The authors reviewed the literature regarding interactions between popular vitamin and mineral supplements and medications used commonly in dentistry. They used clinical databases and decision support tools to classify interactions according to their level of patient risk. They address interactions of greatest clinical concern with a high-quality evidence-based foundation in either randomized controlled clinical trials or meta-analyses.Conclusion.Most medications used commonly in dentistry can be prescribed safely without regard to vitamin- and mineral-drug interactions. However, patients taking anticoagulants or cytochrome P450 3A4 substrates (such as clarithromycin, erythromycin, ketoconazole, itraconazole, midazolam and triazolam) in addition to specific vitamin or mineral supplements (vitamins D, E, K, calcium, fluoride, iron, magnesium, selenium or zinc) may face additional challenges. OHCPs need to recognize these potential interactions and know how to manage the care of patients who may be receiving treatment with these combination therapies.Practical Implications.Recognition and avoidance of potential vitamin- and mineral-drug interactions will help clinicians optimize patient treatment while emphasizing patient safety.     

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.     

Cardiovascular drugs and dental considerations

This paper provides current information on the pharmacologic management of cardiovascular diseases. It also describes the drugs used to treat five common cardiovascular disorders--heart failure, coronary artery disease, atrial fibrillation, hypertension, and unstable angina--and lists their dental implications. This information can be used to monitor patients for potential adverse drug reactions and drug interactions and to provide an information base for medical consultation.     

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.     

Herbs in dentistry

Herbs have been used for centuries to prevent and control disease. Herbal extracts are effective because they interact with specific chemical receptors within the body and are in a pharmacodynamic sense, drugs themselves. By using herbal medicines, patients have averted the many side effects that generally come with traditional medicines, but this does not mean that side effects do not occur. Only knowledgeable practitioners can prescribe the right herb and its proper dosage. Herbal medicines had been considered in every culture, however, pharmaceutical companies overturned this type of thinking. Now, pharmaceuticals are called traditional and herbs are libeled as the 'alternative'. The biggest challenge and problem is lack of information about the effect of herbs in oral tissues, mechanism of effect, and side effects. Several popular conventional drugs on the market are derived from herbs. These include aspirin (from white willow bark), digitalis (from foxglove), and sudafed (modelled after a component in the plant ephedra). Herbal products can vary in their potency. Therefore, care must be taken in selecting herbs, even so, herbal medicines have dramatically fewer side effects and are safer to use than conventional medications. The herbs described in this article are Bloodroot, Caraway, Chamomile, Echinacea, Myrrh, Peppermint, Rosemary, Sage, Thyme, Aloe Vera, Propolis, and a summary of other herbs that are useful in dentistry. Herbs may be good alternatives to current treatments for oral health problems but it is clear that we need more research.     

The dental management of patients with bipolar disorder

Bipolar disorder (manic depressive disease) affects 1% of the United States population. These persons suffer from prolonged episodes of extreme elation and depression. There is a significant incidence of dental pathosis and a need for dental care among these patients. The medications used for the treatment of this disease, their physiologic effects, and their interactions with the drugs used in dentistry are reviewed.