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.     

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.     

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.     

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.     

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.     

牙周优势厌氧菌耐药性的研究进展

牙周厌氧菌是造成牙周炎的主要因素。随着临床治疗中抗生素的滥用,牙周厌氧菌的耐药情况亦愈发普遍。本文就牙周优势厌氧菌及其耐药现状、耐药机制和耐药基因等研究进展作一综述,以期为临床合理使用抗菌药物和新抗菌药物的研发提供依据。     

A survey of drug prescribing practices of dentists

A survey of drug prescribing habits of 357 dentists practicing in five counties in Western New York was conducted in 1986. Respondents represented both general practitioners and specialists who were graduates of 25 different dental schools. From this study it can be concluded that dentists prescribe a wide range of drugs representing over 13 drug categories. The most frequently prescribed drug categories were antibiotics, narcotic analgesics, non-steroidal inflammatory agents, non-narcotic analgesics, and fluorides. The most frequent prescribers of drugs were oral surgeons, endodontists and periodontists.     

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.     

Pharmacology and the elderly

This paper describes the impact of ageing on an individual's ability to process drugs. It considers adverse drug reactions in the elderly and discusses prescribing for the older dental patient. Clinical Relevance: Many older dental patients will be suffering from medical conditions or taking prescribed or non-prescribed drugs. These can influence the impact of drugs prescribed by dentists.     

Diet drugs and cardiac valvulopathy: a survey of dental patients

The recent finding that several appetite suppressant drugs (fenfluramine and dexfenfluramine) were linked to cardiac valvular disease in a significant percentage of the population led to their voluntary withdrawal. The Centers for Disease Control and Prevention issued a series of recommendations in 1997 for evaluating dental patients who had taken these drugs. Since that time, several studies have further investigated the prevalence of valvular abnormalities. This information is crucial because of the problem of dentally associated bacterial endocarditis. This study surveyed more than 1,300 dental patients and determined the prevalence of patients taking these diet drugs and cardiac valvulopathy and the percentage of dental patients required to take antimicrobial endocarditis prophylaxis before "at risk" dental procedures. It remains important for dentists to query their patients for this information.     

Acute localized exanthematous pustulosis: a cutaneous drug reaction in a dental setting

BACKGROUND: Acute generalized exanthematous pustulosis is a severe cutaneous eruption caused most commonly by antibiotics. Rarely, a localized variant of this pustular reaction called "acute localized exanthematous pustulosis" has been described. CASE DESCRIPTION: A 29-year-old woman sought treatment at the authors' dermatology clinic for an outbreak of numerous superficial, nonfollicular pustules with an underlying erythematous base that was accompanied by subjective fever. The lesions appeared two days after the patient began taking amoxicillin prescribed for endocarditis prophylaxis before she underwent a dental cleaning. Cultures were negative for bacteria, and the eruption resolved within four days after the patient discontinued the drug therapy. CLINICAL IMPLICATIONS: Newly revised guidelines for antibiotic prophylaxis for endocarditis indicate that adverse reactions far outweigh the benefits in most cases. It is important that general dentists and oral surgeons recognize this rare pustular eruption, because antibiotics, particularly amoxicillin, are the primary inciting agents. In addition, health professionals should make clinical choices based on evidence, weigh the risks of any treatment plan against its benefits and practice caution when prescribing any drug.     

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.     

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.