A more detailed peek at medications to prevent oral complications
by Deborah Sparks, RDH, BS
As dental hygiene students, we learn from the first week of school how to prevent and manage medical emergencies in our clinics and our offices. We are trained to review our patients' medical histories, as well as to ask questions about their disease status and the medications they take. For many hygienists, though, this is where the conversation stops.
Many medications have not only systemic effects, but oral effects as well. If dental hygienists want to provide comprehensive care to their patients, it is their responsibility to provide counsel to their patients about the oral manifestations of their medications. This article discusses five systemic conditions, commonly prescribed medications for these conditions, and provides information for both hygienists and patients on their oral effects.
► Asthma – Asthmatic patients can be treated with fast-acting bronchodilators such as albuterol (Ventolin, Proventil, etc.). For more chronic asthma, inhaled corticosteroids are the drug of choice.
Routine use of these medications can improve lung function and quality of life, but there are adverse oral effects associated with them. The primary oral effect is that of oral candidiasis (thrush). Candidiasis is caused by the fungus Candida albicans. It can appear as white cheese curds that, when wiped off, leave a raw and sometimes bleeding surface.
Instruct your patients that careful rinsing after each use can prevent steroid-induced candidiasis. Candidiasis due to the immunosuppressant effects of steroids can be treated with nystatin (Mycostatin) tablets.
One commonly prescribed bronchodilator/corticosteroid is fluticasone (Advair, Flovent).
► Cerebrovascular accidents – Cerebrovascular accidents (CVA), or strokes, are caused by many vascular conditions, but blood viscosity also plays a role. When blood is thickened by disease, there is a greater chance of clots forming.
After experiencing a CVA, many patients are prescribed medications to thin their blood. When on a blood thinner, patients are required to have their blood clotting time measured by an INR (international normalized ratio) test on a regular basis to prevent being overmedicated and possibly experiencing abnormal bleeding. Be aware that patients taking prescription blood thinners may also self-medicate with NSAIDs as well as OTC supplements, compounding the effects of the prescription medications.
Inquire as to when your patient has had their most recent INR test and whether their medication dosage was adjusted. If their INR results are stable, they will usually not have their dosage changed.
Oral manifestations of blood thinners can range from hemorrhagic tissues during routine prophylaxis to uncontrolled bleeding during surgical procedures. An example of our professional role would be to note where petechiae are found in the patient's chart and make the patient aware of their location. Petechiae could be a result of blood thinners. It is recommended that patients with INR readings of over 3.5 not be treated.
The most commonly prescribed blood thinner is warfarin (Coumadin).
► Hypertension– A commonly prescribed group of medications for hypertensive patients are calcium channel blockers (CCB). These medications interrupt the movement of calcium into the cells of the heart and blood vessels to produce vasodilation. CCBs can also be prescribed for other cardiovascular diseases such as angina as well as for noncardiac issues such as orofacial pain and migraine headaches.
The most significant oral manifestation of CCBs is gingival enlargement. Though gingival enlargement can be controlled by meticulous oral hygiene and is reversible when the patient discontinues the drug use, it is wise to advise patients taking CCBs of this side effect. Another opportunity to provide comprehensive health care while treating hypertensive patients is for hygienists to counsel patients on the causes and effects of hypertension.
Examples of commonly prescribed CCBs include but are not limited to: nifedipine (Procardia), diltiazem (Cardizem), verapamil (Calan, Isoptin), and amlodipine (Norvasc, Lotrel).
► Osteoporosis – While the scope of this article cannot detail the issue of bisphosphonates and oral health, it cannot be complete without addressing it. Bisphosphonates are commonly prescribed for osteoporosis and are sometimes used in cancer treatment.
Over the past several years, there have been increasing concerns regarding the rare, adverse development of osteonecrosis of the jaw (ONJ) induced by bisphosphonates. The risk factors associated with ONJ primarily involve surgical procedures with patients taking IV bisphosphonates. The oral manifestations of those procedures are that of delayed or absent healing of the periodontium, but there have been reports documenting ONJ with patients taking oral medications. The mandible is twice as likely to be affected as the maxilla.
Another contributing factor to ONJ can be ill-fitting dentures that continually irritate the tissues, something that we as hygienists can monitor and advise on. Patients anticipating taking bisphosphonates should be advised to have preventative and restorative treatment prior to taking these medications. Patients receiving oral or IV bisphosphonates should be advised to maintain excellent oral hygiene and have regular dental hygiene maintenance visits.
Examples of commonly prescribed bisphosphonates include but are not limited to: alendronate (Fosamax), ibandronate (Boniva), risedronate (Actonel), and zoledronic acid (Reclast).
► Psychiatric/emotional disorders – Psychotropic drugs prescribed for psychiatric and/or emotional disorders are among the most rapidly growing category of drugs. These medications are not only prescribed for these conditions, but can be used to treat pain and neurological conditions as well.
The primary oral manifestation of these drugs is xerostomia. Xerostomia can make patients susceptible not only to caries and periodontal disease, but to mucositis, which is the inflammation and ulceration of the mucous membranes (and can affect the digestive tract as well).
It is interesting to note that patients often do not realize that they are producing less saliva and experiencing xerostomia until their salivary production is 50% reduced. As hygienists, we are often the first health-care providers to discuss "dry mouth" with our patients. Many physicians, psychiatrists, and pharmacists fail to counsel their patients on this common side effect, and many patients do not realize it may be caused by their medications.
Patients need to be educated on the risks of xerostomia and should be placed on a more frequent maintenance schedule as well as on a caries prevention protocol. Hygienists can help them to be proactive with their oral care and not wait until they are symptomatic or developing caries.
Hygienists have the best opportunity to introduce their patients to saliva substitutes as well as products targeting xerostomia.
In cases of severe xerostomia, pilocarpine (Salagen) can be prescribed. The patient should be advised to discuss this with his/her physician, as there are many contraindications to its use.
Examples of commonly prescribed antipsychotic drugs include but are not limited to: risperidone (Risperdal), quetiapine (Seroquel), and olanzapine (Zyprexa).
Examples of commonly prescribed antidepressants include but are not limited to: sertraline (Zoloft), escitalopram (Lexapro), buproprion (Wellbutrin), citalopram (Celexa), and fluoxetine (Prozac).
Even in today's changing health-care system, the hygienist has more appointment time with his/her patients than most other health-care providers. This advantage offers hygienists a unique opportunity to use this time to educate their patients on both their oral and systemic health.
At your next appointment, consider taking the medical history interview to a higher level and providing more comprehensive care for your patients. When reviewing a medical history, ask questions about the medications your patients are taking. You can begin a dialogue by saying, "I noticed you are taking ________" or "Tell me about ________ ." Ask why they are taking the medication as some drugs are prescribed for off-label use, which means that they are prescribed for a condition other than what the medication is usually intended for.
Other questions that can provide clues to your patient's systemic and oral health include:
- How long have you taken the medication?
- Did it stabilize the condition?
- Have there been any side effects?
Examine the oral cavity for evidence of any drug effects, even if the patient reports none. Discuss your findings with your patient and be ready to provide solutions for adverse effects.
Doing this is not only your professional responsibility, but it will provide your patients with comprehensive care and will enhance patient rapport. You will be surprised at how invaluable this will make you to your patients as well as your practice. Equally important, it will increase your job satisfaction as you will be treating your patient's whole body, not just their oral cavity. Let's make this the future of dental hygiene.
Deborah Sparks, RDH, BS, is a private practice dental hygienist in Chandler, Ariz., and an adjunct faculty member at Mesa Community College in Mesa, Ariz.
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