C123 managing the geriatric patientmanaging the geriatric patient
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  • 1. C123 MANAGING THE GERIATRIC PATIENT ANN ESHENAUR SPOLARICH, RDH, PHD THURSDAY, FEBRUARY 21DISCLAIMER: This work, audio recordings and the accompanying handout, are the intellectual property of the clinician, and permission hasbeen granted to the Chicago Dental Society, its members, successors and assigns, for the unrestricted, absolute, perpetual, worldwide rightto distribute solely as an educational material at the scientific program being presented at the 2011 Midwinter Meeting. Permission has beengranted for this work to be shared for non-commercial education purposes only. No other use, including reproduction, retransmission in anyform or by any means or editing of the information may be made without the written permission of the author. The Chicago Dental Societydoes not assume any responsibility or liability for the content, accuracy, or compliance with applicable laws, and the Chicago Dental Societyshall not be sued for any claim involving the distribution of this work.
  • 2. Chicago Dental Society MWM & REGIONAL MEETING COURSE EVALUATIONSpeaker: Date:Subject: Number of attendees:PLEASE RATE YOUR SPEAKER AS TO: Excellent Good Fair Poor N/A • Subject selected................................. 4 3 2 1 0 • Timeliness of subject ......................... 4 3 2 1 0 • Comprehensiveness........................... 4 3 2 1 0 • Meeting your expectations ................ 4 3 2 1 0 • Content level...................................... 4 3 2 1 0 • Delivery .............................................. 4 3 2 1 0 • Voice quality....................................... 4 3 2 1 0 • Holding your interest ......................... 4 3 2 1 0 • Appropriate audiovisuals ................... 4 3 2 1 0 • Effective audiovisuals ........................ 4 3 2 1 0 • Overall evaluation of speaker ............ 4 3 2 1 0 • Overall evaluation of program........... 4 3 2 1 0Should this speaker be invited for future meetings? Yes q No qWhat topics of interest would you like to see covered in the future?Comments (use reverse if you need additional space):Name (requested but not required—please print):RETURN EVALUATION CARD TO: DO NOT FOLD CARD. FOR CDS PERMANENT FILES.Chicago Dental SocietyAloysius F. Kleszynski, DDS401 N. Michigan Ave., Suite 200, Chicago, IL 60611-5585
  • 3. COURSE TITLE: Pharmacologic Management of the Geriatric Patient: Oral Health Care ConsiderationsCOURSE INSTRUCTOR: Ann Eshenaur Spolarich, RDH, PhDCOURSE CREDITS: 3 CEUsCOURSE DATE: February 22, 2013_____________________________________________________________________________COURSE DESCRIPTION: The purpose of this course is to review characteristics and diseasetrends among the aging population, and oral disease risks associated with medications andcommon systemic diseases. Most patients take multiple medications, many of which have oralcomplications and drug interactions of significance to dentistry. Medication therapies, oral drugand disease complications, drug interactions and dental practice management considerations willbe discussed. Recommendations for treatment modifications and oral hygiene self-care programswill be provided.LEARNING OBJECTIVES:Upon completion of this continuing education program, course participants will be able to:1. Describe common oral disorders observed in the elderly population, including xerostomia, taste and smell disorders, orofacial muscular disorders, and lichenoid drug reactions.2. Discuss the pathophysiology of common diseases associated with aging, including cardiovascular disease, gastrointestinal problems, and depression.2. Identify the major classes of medications associated with and/or used to treat these conditions.4. Discuss the oral side effects and other adverse events associated with each of these disease states and related medication therapies.5. Identify modifications necessary to safely treat patients who present with these medical conditions.6. Recommend appropriate oral hygiene strategies for each of these patient populations.*These course materials may not be duplicated without the written consent of the courseinstructor. 1
  • 4. I. Selected Agents for the Treatment of Depression -dopamine-reuptake inhibitor - bupropion (Wellbutrin, Zyban) -depression, smoking cessation -increased risk for seizures; alcohol lowers seizure threshold -risk for emergent hypertension *take BP on patients using this drug -monoamine oxidase inhibitors (MAOIs) -isocarboxazid (Marplan) -phenelzine (Nardil) -selegiline (Atapryl, Eldepryl, Selpak) -tranylcypromine (Parnate) -atypical, non-endogenous or neurotic depression -depression associated with Parkinson’s disease -investigational for ADHD, Alzheimer’s, Schizophrenia -post-traumatic stress disorder *take BP on patients using these drugs -selective serotonin reuptake inhibitors (SSRIs) -citalopram (Celexa) -escitalopram oxalate (Lexapro) -fluoxetine (Prozac, Sarafem) -paroxetine (Paxil) -sertraline (Zoloft) -over 15 approved indications -depression, geriatric depression, generalized anxiety disorder, social phobias, social anxiety disorders, diabetic neuropathies, anorexia, bulimia, premenstrual syndrome, obsessive compulsive disorder (OCD), panic attacks/disorders *biggest US market sellers: Paxil and Zoloft -sertraline (Zoloft) is only drug approved for use in children for OCD -recent concerns over whether use of SSRIs in adolescents increases risk for suicide: increased number of cases of suicide attempts prompted FDA to require relabeling of these drugs -agitation, anxiety, hostility, aggression = known side effects -watch for signs of change in depression and related behaviors or any of the above side effects during first 6 weeks of therapy: highest risk time period for suicide attempt -venlafaxine (Effexor) -selective serotonin/norepinephrine reuptake inhibitor -depression, anxiety, panic disorder; investigational for OCD, hot flashes, neuropathic pain, ADHD -raises BP (diastolic) and heart rate *take BP on patients using this drug -tetracyclic - maprotiline (Ludiomil) -depression, anxiety with depression -investigational:bulimia, enuresis, pain, panic attacks, tension headaches, cocaine withdrawal -tricyclics (secondary amines) -amoxapine (Ascendin) -desipramine (Norpramin) -nortriptyline (Aventyl, Pamelor) -protriptyline (Vivactil) 2
  • 5. -treatment of depression in conjunction with psychotherapy -adjunctive therapy for chronic pain, peripheral neuropathies -investigational for substance-related disorders, ADHD -tricyclics (tertiary amines) -amitriptyline (Elavil, Vanatrip) -clomipramine (Anafranil) -doxepin (Sinequan) -imipramine (Tofranil) -trimipramine (Surmontil) -treatment of depression with psychotherapy -chronic pain, neuropathic pain, migraines, depression with anxiety *take BP on patients using these drugs General Adverse Effects - orthostatic hypotension - sedation - dizziness, light-headednessII. MAJOR TRANQUILIZERS/ANTIPSYCHOTICSA. Pharmacology and Use -Older term: neuroleptic drugs -A chemically diverse but pharmacologically similar class of drugs used to treat a variety of conditions -Used in the treatment of: -Psychotic disorders – Schizophrenia, paranoia -Acute delirium and dementia -Manic episodes during induction of lithium -Movement disorders – Huntington’ disease, Tourette’s syndrome, ballismus -Intractable hiccups -Severe nausea and vomiting -Individual drugs bind to a variety of receptors and act as antagonists: -dopaminergic, alpha1 and alpha2 adrenergic, serotonergic (5-HT), muscarinic, H1 histamine, sigma opioid -Blockade of dopaminergic transmission in various areas of brain is thought to be responsible for their major effects -Antipsychotic action = blockage in prefrontal cortex and limbic areas -Extrapyramidal side effects = blockade in basal ganglia -Antiemetic effects = blockade in chemoreceptor trigger zone of the medulla -All antipsychotics have high therapeutic index -Not addictive 3
  • 6. B. Side Effects -Extrapyramidal side effects: Parkinsonism – akinesia (difficulties in initiating movement), tremor, rigidity Caused by blockade of D2 receptors in basal ganglia -Akathisia = restless legs syndrome; Caused by D2 receptor blockage in basal ganglia -Dystonia – sustained muscular contraction -Tardive Dyskinesia – abnormal movements, particularly of face and tongue, but may also be of trunk and limbs -Noticeable after at least 6 months of chronic treatment - begins with spastic, thrusting tongue movement, body restlessness, changes in HR & respiration *Most extrapyramidal side effects are treatable with anticholinergic drugs Sedation and autonomic side effects are caused by blockade of histamine, cholinergic and adrenergic receptors -orthostatic hypotension -blurred vision -dry mouth -nasal congestion -constipation -urinary retentionC. Drug Interactions of Significance to Dentistry -Antipsychotics potentiate the actions of -sedatives -analgesics -antihistamines -Antipsychotics potentiate the respiratory depression caused by opioids -Antacids = decrease absorption of antipsychotics -Anticonvulsants = decrease plasma levels of antipsychotics -Antipsychotics may alter efficacy of antihypertensive medications *monitor vital signsTYPICAL ANTIPSYCHOTICS ATYPICAL ANTIPSYCHOTICSchlorpromazine (Thorazine) = Schizophrenia, aripiprazole (Abilify) = Commonly used agent innausea/vomiting, intractable hiccups, schizophrenia, treatment and stabilization ofcombativeness bipolar disorder -Low risk of EPS -Does not cause as much weight gain as other antipsychotics, but may be less effective than othersfluphenazine (Prolixin) = management of clozapine (Clozaril) = Schizophrenia; severe OCD,psychotic disorders and schizophrenia; improves childhood psychosis, attempted suicide, substanceoutcomes in patients with psychoses who are abuse recoverynonadherent with oral antipsychotics Side effect: agranulocytosis – susceptibility to infection, hypersalivation (others cause xerostomia), weight gain, reduced risk of EPS 4
  • 7. haloperidol (Haldol) olanzapine (Zyprexa) = Schizophrenia, bipolarRX for schizophrenia and Tourette’s; severe disorder, acute agitationbehavioral problems in children-EPS of TMJpimozide (Orap) = suppression of severe motor and olanzapine and fluoxetine (Symbyax) = treatmentphonic tics with Tourette’s of depressive episodes associated with bipolar-prolongs QT interval: consult physician prior to disorderadministering vasoconstrictorprochlorperazine (Compro, Compazine) = paliperidone (Invega) = Schizophreniaantiemetic; psychosis, anxiety-EPS side effect: torticollis (neck muscle spasm)promethazine (Phenadoz, Phenergan, quetiapine (Seroquel) = Schizophrenia, acutePromethegan) = antiemetic, antihistamine, manic episodes and/or depressive episodes withsedative, motion sickness, post-operative pain, bipolar disorder (monotherapy or with lithium)anesthetic-EPS side effect: tardive dyskinesia, Parkinson’ssyndrome, akathisia is most common in elderlypatientsthiothixene (Navane) = psychotic disorders in risperdone (Risperdal) = Commonly used agent inchildren, rapid tranquilization of agitated child; schizophrenia, acute mania and/orpatients with dementia irritability/aggression with bipolar disorder,-prolongs QT interval: consult physician prior to behavioral problems with dementia, Tourette’sadministering vasoconstrictor ziprasidone (Geodon) = schizophrenia, acute manic or mixed episodes with bipolar disorder with or without psychosis, acute agitation with schizophrenia -prolongs QT interval: consult physician prior to administering vasoconstrictorWhy are Cholinesterase Inhibitors typically used? • Indirect-Acting Cholinergic Drugs • Also known as “cholinesterase inhibitors” • These drugs stop the breakdown of acetylcholine (via cholinesterase), which allows for the concentration of acetylcholine to build up = acetylcholine remains active and stimulates the PANS • These drugs produce PANS stimulation • Dementia with Alzheimer’s disease • Investigational for mild to moderate dementia with Parkinson’s disease • Examples: o donepezil (Aricept) o rivastigmine (Exelon) o galantamine (Razadyne)Side Effects of Direct-Acting and Indirect-Acting Cholinergic Drugs • nausea, vomiting, diarrhea (by increasing GI activity) • salivation, sweating (increased gland secretions) • bronchoconstriction 5
  • 8. • constricted pupils • Paralysis at high doses (effect at neuromuscular junction) • CNS = confusionAnticholinergic Drugs for Parkinson’s Disease • benztropine (Cogentin) • trihexyhenidyl (not in U.S.; Canadian drug)Anticholinergic Drugs (Parasympatholytics) • Prevent the action of acetylcholine at the postganglionic PANS nerve endings • “blocker” drugs or antagonists • Block the receptor site for acetylcholine • Do not prevent release of ACH • Acetylcholine cannot act on receptors in smooth muscle, glands or the heart • Also called antimuscarinic drugs (block muscarinic receptors but not nicotinic receptors)Pharmacologic Effects of Anticholinergic Drugs • Reduce PANS activity o Skin = decrease sweating o GI = decrease salivation, decreased gut motility o Urinary tract = urine retention o Respiratory = bronchodilation o CNS = decreased concentration/memory; sedation; possible hallucinations and comaAdverse Reactions to Anticholinergic Drugs • Frequently are extensions of their pharmacologic effects • Xerostomia • Blurred vision, photophobia • Tachycardia • Fever • Urinary and GI stasis • Hyperpyrexia (elevated temperature) • Hot, dry flushed skin (lack of sweating) • Toxicity = CNS excitation = delirium, hallucinations, convulsions, respiratory depressionIII. ORAL HEALTH CONSIDERATIONS FOR NEUROPSYCHIATRIC CONDITIONS - most neuropsychiatric medications cause xerostomia -watch for opportunistic infections -loss of protective effects: viral, fungal, bacterial infections -traumatic aphthous ulcers - lack of interest in performing daily self-care - increased demineralization, caries and gingival disease - lack of interest/motivation to seek treatment 6
  • 9. - caution with epinephrine = Monitor vital signs! -use vasoconstrictors cautiously with all classes of antidepressants except SSRIs -tricyclics and monoamine oxidase inhibitors -venlafaxine (Effexor) – depression, anxiety, OCD, ADHD --all drugs for ADHD -some antipsychotics = consult drug reference guide -SSRIs = bruxism: increased extrapyramidal effects -burning mouth syndrome = observed in depression and anxiety; tricyclicsIV. PEPTIC ULCER DISEASE1. Incidence and Prevalence -among most common human ailments -peak prevalence occurs in young adulthood (age 30 to 50 years) -first degree relatives have threefold higher risk -higher prevalence seen among: -smokers -heavy drinkers -hyperparathyroidism -renal dialysis patients -use of NSAIDS for longer than 1 month -death (from complications) of disease occur in elderly2. Etiology -primary aggressive factor: Helicobacter pylori infection -present in more than 90% of cases -contributing factors: -acid hypersecretion -cigarette smoking -psychological and physical stress – increases acid secretion -use of NSAIDS for longer than 1 month -NSAID-induced ulcers occur more often in stomach than duodenum -concomitant use of aspirin, alcohol, corticosteroids and anticoagulants increases risk -obsessive compulsive disorder – increases acid secretion -caffeine – increases acid secretion -alcohol – alters cell permeability, leads to cell death = injures mucosa3. Treatment -if ulcer is confined and uncomplicated: antisecretory drugs -if H pylori is present: antisecretory drugs with antimicrobials -combination therapy is used: -tetracycline and metronidazole or amoxicillin and clarithromycin with proton-pump inhibitor or bismuth subsalicylate (Pepto-Bismol) -treatment lasts for 2 weeks -modification of factors that contribute to ulceration 7
  • 10. Medications - OTC antacids - weak bases that interact with stomach acid to form water and salt; raise gastric pH - composition: aluminum hydroxide, magnesium hydroxide, calcium carbonate - Histamine H2 receptor antagonists - OTC meds used to manage symptoms of heartburn, acid indigestion, benign gastric and duodenal ulcers, GERD, hypersecretory conditions and erosive esophagitis - cimetidine (Tagamet), famotidine (Pepcid), nizatidine (Axid) and ranitidine hydrochloride (Zantac) - Proton pump inhibitors - bind to H+/K+-ATPase enzyme system (proton pump) in parietal cells which reduces acid secretion - reduce gastric secretions, neutralize gastric acid after release, protect gastric mucosa from damage -chronic use is linked to stomach cancer -associated with osteoporosis and risk for hip fracture - esomeprazole (Nexium), lansoprazole (Prevacid), omeprazole (Prilosec), pantoprazole (Protonix), esomeprazole (Nexium), rabeprazole (Aciphex)4. Dental Considerations -thorough medical history review for risk factors and symptoms -avoid prescribing: aspirin, aspirin-containing products, NSAIDS -use acetaminophen (Tylenol) -Cox-2 inhibitors (Celebrex) -H2 receptor blockers like cimetidine (Tagament) decrease the metabolism of many drugs: -diazepam, lidocaine (adjust dosage) -H pylori is found in dental plaque = reservoir for infection/reinfection -good oral hygiene; frequent scaling and root planing -use of antibiotics = Candidiasis will require antifungal therapy -oral manifestations of peptic ulcer disease: -vascular malformations of lip (macules, venous pool) -enamel erosion -GI medications: -taste alteration -blood dyscrasias = increased risk for infections, bleeding -xerostomia - OTC antacids bind to other meds in the stomach = antacids and tetracycline - OTC antacids alter absorption, bioavailability and elimination of many drugs - wait 2 hours before/after taking antacids before taking other meds - histamine H2 receptor antagonists and proton pump inhibitors decrease the availability of azole antifungals - Tagamet and Zantac alter effects of warfarin - Tagamet increases serum concentrations of some benzodiazepines, lidocaine and the quinolone antibiotics 8
  • 11. DRUG ORAL SIDE EFFECTS omeprazole (Prilosec®) xerostomia, taste alteration, esophageal candidiasis, pharyngeal pain pantoprazole (Protonix®) xerostomia, taste alteration, pharyngitis, increased cough, aphthous stomatitis, gingivitis, glossitis, halitosis, oral moniliasis, tongue discoloration, herpes simplex, erythema multiforme nizatidine (Axid®) xerostomia, laryngeal edema ranitidine bismuth citrate (Tritec®) taste alteration, darkening of tongue ranitidine hydrochloride (Zantac®) erythema multiforme rabeprazole (Aciphex™) xerostomia, mouth ulcerations esomeprazole (Nexium™) xerostomia, ulcerative stomatitis, taste lossOral side effects associated with gastrointestinal medicationsV. CARDIOVASCULAR DISEASEDRUGS THAT ALTER BLEEDINGANTIPLATELET MEDICATIONS -aspirin = antiplatelet drug -blocks cyclo-oxygenase, an enzyme associated with clot formation -inhibits platelet aggregation -prevents thrombus formation on atherosclerotic plaques -lowers risk of MI in those with increased risk for atherosclerosis/thrombogenesis -lowers risk of MI and stroke in those with previous history of MI and stroke, unstable angina, post-coronary artery bypass grafting -one enteric coated 325 mg tablet of aspirin daily or 81 mg low dose aspirinSudden Discontinuation of Aspirin Discontinuing the use of aspirin increases mortality risk 1 Large clinical trial (n=1358) with hospitalized patients with an acute coronary syndrome 2 3 groups: never taken an oral antiplatelet agent (n=930), Hx of prior use (n=355), recently discontinued use (n=73) Among recently discontinued aspirin group, mostly due to physician recommendation prior to surgery, there was a higher 30 day rate of death or MI and adverse bleedings than among prior users No difference in the incidence of death or MI at 30 days between nonusers and prior users. Recent withdrawal displayed worse clinical outcomes than nonusers. 1. Ho PM, Spertus JA, Masoudi FA, et al. Impact of medication therapy discontinuation on mortality after myocardial infarction. Arch Intern Med. 2006 Sep 25;166(17):1842-7. 2. Collet JP, Montalscot G, Blanchet B, et al. Impact of prior use or recent withdrawal of oral antiplatelet agents on acute coronary syndromes. Circulation. 2004 Oct 19;110(16):2361-7. Epub 2004 Oct 11. A meta-analysis reviewing data from over 50,000 patients showed that aspirin non- adherence/withdrawal was associated with a three-fold higher risk for major adverse cardiac events. 3 Risk was even greater among patients with coronary stents. Risk was amplified by a factor of 89 in patient who had undergone stenting. 9
  • 12. 3. Biondi-Zoccai GG, Lotrionte M, Agostoni P, et al. A systematic review and meta-analysis on the hazards of discontinuing ornot adhering to aspirin among 50,279 patients at risk for coronary artery disease. Eur Heart J. 2006 Nov;27(22):2667-74. Epub2006 Oct 19.other anti-platelet medications: aspirin and dipyridamole (Aggrenox) cilostazole (Pletal) ticlopidine (Ticlid) – used for those who are intolerant to aspirin, when aspirin therapy has failed, and coronary stent implantation Lowers risk of stent thrombosis Low risk of bleeding complications compared to other strategies clopidogrel (Plavix) Replaced use of ticlopidine Lower rates of major adverse cardiac events and mortality compared with ticlopidine Better safety-tolerability profile Lower risk of neutropenia Indications: reduce rate of TE (MI, stroke, vascular death) in patients with recent MI or stroke; reduce rate of TE in patients with unstable angina managed medically or with PCI (with or without stents); reduces rate of death and TE in patients with ST-Sement elevation MI managed medically Dosing: 300 mg loading dose; 75 mg daily (with aspirin 81-325 mg daily) Problems: Drug interactions Slow onset of action Wide variability in patient response Includes “no” response prasugrel (Effient) *new drug approved in July 2009 Approved for patients with acute coronary syndromes undergoing PCI Indications: Reduces rate of thrombotic cardiovascular events (eg, stent thrombosis) in patients with unstable angina, non-ST-segment elevation MI, or ST-elevation MI (STEMI) managed with percutaneous coronary intervention Loading dose of 60 mg followed by maintenance dose of 10 mg Manufacturer labeling states to also take 75-325 mg aspirin once daily upon recommendation of provider clopidogrel (Plavix) and prasugrel (Effient) Prodrugs Noncompetitive antagonists of P2Y12 receptor Inhibit ability of adenosine diphosphate (ADP) to induce platelet aggregation and decreases subsequent platelet aggregation Block receptor for the life of the platelet = irreversible effect action is independent of and additive to aspirinPrevention of premature discontinuation of dual antiplatelet therapyin patients with coronary artery stents: a science advisory from theAmerican Heart Association, American College of Cardiology, Society 10
  • 13. for Cardiovascular Angiography and Interventions, American Collegeof Surgeons, and American Dental Association, with representationfrom the American College of Physicians.Grines CL, Bonow RO, Casey DE Jr, Gardner TJ, Lockhart PB, Moliterno DJ, OGara P, Whitlow P; AmericanHeart Association; American College of Cardiology; Society for Cardiovascular Angiography and Interventions;American College of Surgeons; American Dental Association; American College of Physicians. William BeaumontHospital, Royal Oak, Michigan, USA. J Am Dent Assoc. 2007 May;138(5):652-5.AbstractBACKGROUND: and Overview. Dual antiplatelet therapy with aspirin and a thienopyridine has beenshown to reduce cardiac events after coronary stenting. However, many patients and health care providersprematurely discontinue dual antiplatelet therapy, which greatly increases the risk of stent thrombosis,myocardial infarction and death. CONCLUSIONS AND CLINICAL IMPLICATIONS: This advisorystresses the importance of 12 months of dual antiplatelet therapy after placement of a drug-eluting stentand educating patients and health care providers about hazards of premature discontinuation. It alsorecommends postponing elective surgery for one year, and if surgery cannot be deferred, considering thecontinuation of aspirin during the perioperative period in high-risk patients with drug-eluting stents.PMID: 17473044*Link to download free full text copy: http://jada.ada.org/cgi/content/full/138/5/6523 Recommendations from Advisory Statement (listed above): Those concerned about peri/postprocedural bleeding must be aware of catastrophic risks of premature discontinuation -Consult cardiologist to discuss optimal patient management strategies Elective procedures with significant risk of peri/postoperative bleeding should be deferred until patient has completed an appropriate course of thienopyridine therapy: -12 months after DES implantation if they are not at high risk of bleeding -Minimum of one month for bare-metal stent implantation Patients with DES who are to undergo subsequent procedures that mandate discontinuation of drug therapy, aspirin should be continued if at all possible -Restart thienopyridine as soon as possible after the procedure because of concerns of late stent thrombosisplatelet glycoprotein IIb/IIIa receptor antagonists (fibrinogen receptor inhibitors): -used in combination with aspirin and heparin to treat unstable angina -decrease the incidence of death and MI -inhibit final common pathway involved in adhesion, activation, aggregation abciximab (ReoPro) eptifibatide (Integrilin) tirofiban (Aggrastat) 11
  • 14. NSAIDSIbuprofen has a very short half-life (2-4 hours) Withhold for 4-6 half-lives prior to invasive dental surgical procedures (about 1 day prior to treatment)Cause bleeding as a side effect, especially GI bleedingFDA Black Box Warning: NSAIDs are associated with an increased risk of adversecardiovascular thrombotic events, including fatal MI and stroke. In 2006, the FDA issued an informational statement to healthcare professionals statingthat “ibuprofen can interfere with the anti-platelet effect of low dose aspirin (81 mg perday), potentially rendering aspirin less effective when used for cardioprotection andstroke prevention. Healthcare professionals should advise consumers and patientsregarding the appropriate concomitant use of ibuprofen and aspirin.” 1 The concern isthat concurrent use of these medications can increase risk for adverse cardiac events,and thus, the FDA issued the following considerations: • “Counseling patients about the appropriate timing of ibuprofen dosing if they are also taking aspirin for cardioprotective effects. • With occasional use of ibuprofen, there is likely to be minimal risk from any attenuation of the antiplatelet effect of low dose aspirin, because of the long-lasting effect of aspirin on platelets. • Patients who use immediate release aspirin (not enteric coated) and take a single dose of ibuprofen 400 mg should dose the ibuprofen at least 30 minutes or longer after aspirin ingestion, or more than 8 hours before aspirin ingestion to avoid attenuation of aspirin’s effect. • Recommendations about the timing of concomitant use of ibuprofen and enteric-coated low dose aspirin cannot be made based upon available data. • Other nonselective OTC NSAIDs should be viewed as having the potential to interfere with the antiplatelet effect of low-dose aspirin unless proven otherwise. • Prescribing analgesics that do not interfere with the antiplatelet effect of low dose aspirin for high risk populations.” 11. U.S. Food and Drug Administration. U. S. Department of Health and Human Services. Information for HealthcareProfessionals: Concomitant Use of Ibuprofen and Aspirin. New Information [9/2006] - Concomitant Use of Ibuprofen andAspirin. Available at:http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm125222.htmANTICOAGULANT MEDICATIONS • Antithrombins o antithrombin o heparin • Coumarin derivatives o warfarin (Coumadin, Jantoven) • Thrombin inhibitors o argatroban – px/tx of thrombosis with heparin-induced thrombocytopenia (HIT); adjunct to PCI if at risk for HIT 12
  • 15. o bivalirudin (Angiomax) – with ASA for unstable angina receiving PCI; undergoing PCI with risk for HIT o dabigatran etexilate (Pradaxa) – thromboprophylaxis for hip/knee replacement o desirudin (Iprivask) – prophylaxis of DVT for hip replacement o fondaparinux (Arixtra) – thromboprophylaxis for hip/knee replacement o lepirudin (Refludan) – anticoagulation with HIT o rivaroxaban (Xarelto) – thromboprophylaxis for hip/knee replacementANTITHROMBINS• Antithrombin III (Atryn, Thrombate III) o given to those with an antithrombin III deficiency• Heparin - enhances the inhibition rate of clotting proteases by antithrombin III impairing normal hemostasis and inhibition of factor Xa.• Low molecular weight heparins - strongly inhibit factor Xa; higher ratio of antifactor Xa to antifactor IIa activity than unfractionated heparin.Heparin• Naturally-produced anticoagulant (anti-thrombin)• Synthetic version given by IV• Indications: prevention and treatment of thromboembolic disorders• Anticoagulant for dialysis procedures• Heparin Lock flush used to clear IV lines• Produces immediate anticoagulation effect• Patient admitted to hospital is started on heparin and warfarin: heparin produces initial effectLow Molecular Weight Heparins• Use: prevention of DVT with or without PE; reduce risk for PE; acute unstable angina; non-Q- wave MI• Mechanism: Inhibit factor Xa and IIa (thrombin) o dalteparin (Fragmin) o enoxaparin (Lovenox) o tinzaparin (Innohep)Indications for enoxaparin (Lovenox)• Acute coronary syndromes: Unstable angina, non-ST-elevation, and ST-elevation MI• DVT prophylaxis: Following hip or knee replacement surgery, abdominal surgery, or in medical patients with severely-restricted mobility during acute illness who are at risk for TE complications• DVT treatment (acute): Inpatient treatment (patients with and without PE and outpatient treatment (patients without PE) o Note: High-risk patients include those with one or more of the following risk factors: >40 years of age, obesity, general anesthesia lasting >30 minutes, malignancy, history of deep vein thrombosis or pulmonary embolism• Used following hip and knee replacement – at least 10 days and o until risk for DVT has subsided or o patient is adequately anticoagulated on warfarin 13
  • 16. COUMARIN DERIVATIVES• warfarin (Coumadin, Jantoven)• interferes with liver synthesis of vitamin-K dependent clotting factors• effects occurs in 4 to 5 days• when patient is admitted to hospital with stroke, there is a 1 to 2 day overlap period with heparin following warfarin administration to prevent hypercoagulable state o Heparin produces immediate effect o Takes 4-5 days for effects of warfarin to occur• Indications for warfarin: o Prophylaxis and treatment of TE disorders (venous and pulmonary) and embolic complications that arise from atrial fibrillation or cardiac valve replacement o Adjunct to reduce risk of systemic embolism (recurrent MI, stroke) after MI• Investigational: prevention of recurrent TIA• Many things can upset a patient’s level of anticoagulation from warfarin: o Fever o Flu o Diarrhea or vomiting o Use of many drugs, including antibiotics o Change in diet (consumption of green leafy vegetables increases vitamin K intake = promotes clotting) Need vitamin K to synthesize clotting factors in liver Warfarin shuts off production of these clotting factors**Key messages: warfarin causes the greatest number of drug interactions o Always check compatibility prior to issuing a prescription o Always ask about the INR and monitor INR status across time to examine trends in anticoagulation controlTHROMBIN INHIBITORSdabigatran (Pradaxa)• FDA approved October 2010• Thrombin inhibitor• Prodrug = lacks anticoagulant activity o converted in vivo to active dabigatran• specific, reversible, direct thrombin inhibitor that inhibits both free and fibrin-bound thrombin• prevents thrombin-mediated effects, and by inhibiting thrombin-induced platelet aggregation• Dabigatran inhibits coagulation by preventing thrombin-mediated effects, including cleavage of fibrinogen to fibrin monomers, activation of factors V, VIII, XI, and XIII• Indications:• Prevention of stroke and systemic embolism in patients with non-valvular atrial fibrillation• Postoperative thromboprophylaxis after total hip or knee replacement o Knee replacement – up to 10 days o Hip replacement – up to 35 days• compared to warfarin (Coumadin)• advantages: no monthly monitoring; fewer drug-drug and drug-diet interactions• disadvantages: very expensive; twice daily dosing 14
  • 17. • in studies, patients who took Pradaxa had fewer strokes than those taking warfarin o RE-LY trial = Randomized Evaluation of Long-Term Anticoagulation Therapy• adverse effects: bleeding, GI effectsIndications for Direct Antithrombins (Thrombin Inhibitors)• Prevent/reduce ischemia with unstable angina• Prevent DVT following hip replacement• Prevent/treat thromboembolism• Treatment of heparin-induced thrombocytopenia (HIT)rivaroxaban (Xarelto) (riv a ROX a ban)• New drug – FDA approval announced July 1, 2011• First and only oral anticoagulant approved in US for orthopedic surgery• Factor Xa inhibitor• Mechanism: inhibits platelet activation and fibrin clot formation via direct, selective, and reversible inhibition of factor Xa in both the intrinsic and extrinsic coagulation pathways• Indications: o Postoperative thromboprophylaxis in patients who have undergone hip or knee replacement surgery• Adults: Postoperative thromboprophylaxis: o Knee replacement: 10 mg once daily; recommended total duration of therapy: 12-14 days o Hip replacement: 10 mg once daily; total duration of therapy: 35 daysfondaparinux (Arixtra) (fon da PARE i nuks)• Factor Xa inhibitor o causes an antithrombin III-mediated selective inhibition of factor Xa• Interrupts the blood coagulation cascade and inhibits thrombin formation and thrombus development• Indications:• Prophylaxis of deep vein thrombosis (DVT) in patients undergoing surgery for hip replacement and knee replacement• hip fracture (including extended prophylaxis following hip fracture surgery)• abdominal surgery (in patients at risk for thromboembolic complications)• treatment of acute pulmonary embolism (PE)• treatment of acute DVT without PE• Usual duration: 5-9 days o up to 10 days following abdominal surgery o up to 11 days following hip replacement or knee replacement• Extended prophylaxis is recommended following hip fracture surgery o has been tolerated for up to 32 days total• Acute DVT/PE treatment: o Note: Start warfarin on the first treatment day and continue fondaparinux until INR is between 2 and 3 (usually 5-7 days) (Hirsh, 2008) 15
  • 18. COMMON ORAL PROBLEMS IN ELDERLY PATIENTSDisease or Drug Induced Xerostomia Caries and Demineralization Tooth Sensitivity Periodontal Disease Fungal Infections Viral Infections Pain and Ulcerations Food Packing/Decreased Oral ClearanceOral signs and symptoms associated with drug-induced xerostomiaCaries Enamel demineralizationEnamel erosion Cemental abrasion on exposed root surfacesDentinal hypersensitivity Increased gingivitis and periodontal infectionOpportunistic infections Increased viral infectionsOral ulcerations/stomatitis Taste alterationDry, cracked, bleeding lips Fissured, sore tongueAngular cheilitis Friable oral mucosaDifficulty speaking, chewing, Difficulty wearing dentures or appliancesswallowingDrug classes that produce neural effects on the salivary glandsThe following are examples of anticholinergic drugs that reduce the volume of serous saliva:Antidepressants Antiemetics Antihistamines AntihypertensivesAnti-parkinsonian drugs Antipsychotics AntispasmodicsThe following are examples of sympathomimetic drugs that produce a viscous, mucinous saliva:Amphetamines Appetite suppressantsBronchodilators DecongestantsSources: Sreeby LM, Schwartz SS: A reference guide to drugs and dry mouth, 2nd ed, Gerodontol 14:33-47, 1997;Porter SR,Scully C, Hegarty AM: An update of the etiology and management of xerostomia, Oral Surg Oral Med Oral Pathol Pral RadiolEndod 97:28-46, 2004; Nähri TO, Meurman JH, Ainamo A: Xerostomia and hyposalivation: causes, consequences andtreatment in the elderly, Drugs & Aging 15:103-116, 1999.Drug classes associated with causing xerostomiaAntiacne agents Antianxiety agents Anticholinergics/AntispasmodicsAnticonvulsants Antidepressants AntidiarrhealsAntiemetics Antihistamines AntihypertensivesAnti-inflammatory analgesics Antinauseants Anti-parkinsonian agents 16
  • 19. Antipsychotics Anorexiants BronchodilatorsDecongestants Diuretics Muscle RelaxantsNarcotic Analgesics SedativesSource: USP DI® Drug Information for the Healthcare Professional, vol 1, ed. 24, Englewood, CO, Micromedix, Inc., 2004.Taste and Smell DisordersDrugs that alter tasteAlcohol detoxification agents Alzheimer’s medicationsAnalgesics (NSAIDS) Anesthetics (general and local)Anorexiants AntacidsAntianxiety agents AntiarthriticsAnticholinergics AnticonvulsantsAntidepressants Antidiabetics (oral hypoglycemics)Antidiarrheals AntiemeticsAntifungals Antigout medicationsAntihistamine (H1) antagonists Antihistamine (H2) antagonistsAntihyperlipidemics AntiinfectivesAnti-inflammatory/antiarthritics Antimigraine agentsAntiparkinson agents AntipsychoticsAntithyroid medications AntiviralsAnxiolytics/sedatives Asthma preventivesBronchodilators Calcium-affecting drugsCancer chemotherapeutics Cardiovascular medicationsCNS stimulants DecongestantsDiuretics GlucocorticoidsGallstone solubilization agents HemorheologicsImmunomodulators ImmunosuppressantsIrritable bowel syndrome medications MethylxanthinesNicotine replacement drugs OphthalmicsProton pump inhibitors Retinoids, systemicSalivary stimulants Skeletal muscle relaxantsVitaminsSource: Gage TW, Pickett FA: Mosby’s dental drug reference, ed. 7, St. Louis, 2005, Elsevier Mosby. 17
  • 20. Systemic drugs associated with lichenoid drug reactionsCategory AgentsAnalgesic agents NSAIDs, propoxyphene/acetaminophen, acetaminophen/codeineAntianxiety drugs benzodiazepinesAntiarrhythmics quinidineAnticonvulsant drugs DepakoteAntineoplastic drugs levamisoleCardiovascular agents Beta-adrenergic blockers, angiotensin II antagonist, calcium channel blockers, cardiac glycoside, methyldopa, thiazide diuretics, potassium supplementsGastric acid secretion inhibitors H2-antagonistsHormone replacement Thyroid hormone, insulin, sulfonylureas, metformin, oral contraceptives, estrogen, progesteronePhotographic DyesUricosuric agent Allopurinol 18
  • 21. COURSE TITLE: Commonly Prescribed Medications and Managing the Oral Side Effects of Medication UseCOURSE INSTRUCTOR: Ann Eshenaur Spolarich, RDH, PhDCOURSE CREDITS: 3 HoursCOURSE DATE: February 21, 2013________________________________________________________________________COURSE DESCRIPTION:The purpose of this course is to review the 20 most commonly prescribed medications taken byclients treated in the oral health care environment. In addition, drug interactions, popular drugsin the media and new drugs in dentistry will be discussed. A comprehensive review of drugs anddental care products used to manage the oral side effects of medications will be presented.LEARNING OBJECTIVES:Upon completion of this continuing education course, the participant will be able to:1. Identify and discuss commonly prescribed medications taken by clients treated in the oral health care setting.2. Identify common drug interactions of significance to dental professionals.3. List several new dental drugs and discuss their indications for use in practice.4. Discuss the management of oral side effects caused by medications.*This material may not be reproduced without the written permission of the author. 1
  • 22. TOP 20 MOST COMMONLY PRESCRIBED MEDS 2011 (Total Prescriptions Dispensed)1. hydrocodone and acetaminophen 2. hydrocodone and acetaminophen3. levothyroxine sodium 4. lisinopril5. Lipitor 6. simvastatin7. Plavix 8. Singulair9. azithromycin 10. Crestor11. Nexium 12. levothyroxine sodium13. metoprolol tartrate 14. hydrocodone and acetaminophen15. Synthroid 16. Lexapro17. Proair HFA 18. ibuprofen19. trazodone HCl 20. amoxicillinINDICATIONS DRUGSpain relievers hydrocodone and acetaminophen, ibuprofenhypercholesterolemia Lipitor, simvastatin, Crestorhypertension lisinopril, metoprololadverse thromboembolic events Plavixendocrine disorders levothyroxine, Synthroidantibiotics amoxicillin, azithromycinantidepressants Lexapro, trazodoneGERD, reflux or hypersecretory disease Nexiumrespiratory disease Singulair, ProAir HFAPAIN RELIEVERSBRAND NAME: Co-Gesic, hycet, Lorcet, Lortab, Margesic, Maxidone, Norco, Stagesic, Vicodin, Xodol,Zamicet, ZydoneGENERIC NAME: HYCD/APAP (hydrocodone with acetaminophen)THERAPEUTIC CATEGORY: opioid analgesicUSE: post-operative pain controlORAL COMPLICATIONS: xerostomia (rare)DRUG INTERACTIONS: Concurrent use of hydrocodone with MAO inhibitors (Nardil, Parnate,Marplan), tricyclic antidepressants (Elavil) and general anesthetics potentiates the effects of thehydrocodone, and increases the risk for toxicity. Dextroamphetamine enhances the analgesic effect of thehydrocodone. Additive CNS effects may occur when taking hydrocodone with other narcotics,antipsychotics, antianxiety agents, general anesthetics and other CNS depressants (eg. alcohol).Phenothiazines (eg. Thorazine) may decrease the analgesic effect of hydrocodone. Acetaminophen takenwith alcohol, barbituates or carbamazepine (Tegretol) increases the risk for liver toxicity. Chronic use ofacetaminophen may significantly enhance the anticoagulation effects of warfarin (Coumadin). 2
  • 23. BRAND NAME: Caldolor, Ibu, MotrinGENERIC NAME: ibuprofenTHERAPEUTIC CATEGORY: NSAIDUSE: management of mild to moderate pain; inflammatory diseases and rheumatoid disorders, fever,dysmenorrheaORAL COMPLICATIONS: noneDRUG INTERACTIONS: Ibuprofen and other non-selective NSAIDS can interfere with the antiplateletand cardioprotective effects of aspirin: follow appropriate timing of dosing. Avoid use in aspirin-allergicpatients. Ibuprofen may increase the levels of anticoagulants, antiplatelet drugs, bisphosphonates,cyclosporine, digoxin, haloperidol, lithium, methotrexate, NSAIDS, potassium-sparing diuretics,quinolone antibiotics, salicylates, thrombolytic agents, vancomycin and vitamin K antagonists. Levels ofibuprofen may be increased by ACE inhibitors, angiotensin II receptor blockers, antidepressants(tricyclic, teriary amine), systemic corticosteroids, glucosamine, herbs that have anticoagulant orantiplatelet properties, NSAIDS, probenecid, SSRIs, serotonin/norepinephrine reuptake inhibitors.Ibuprofen may decrease the levels of ACE inhibitors, angiotensin II receptor blockers, antiplatelet agents,beta blockers, loop diuretics, potassium-sparing diuretics, salicylates and thiazide diuretics. Levels ofibuprofen may be decreased by bile acid sequestrants, NSAIDS and salicylates. Avoid alcohol.HYPERCHOLESTEROLEMIABRAND NAME: LipitorGENERIC NAME: atorvastatinTHERAPEUTIC CATEGORY: HMG-CoA reductase inhibitorUSE: hypercholesterolemiaORAL COMPLICATIONS: noneDRUG INTERACTIONS: The risk for myopathy/rhabdomyolysis is increased with concurrent use of themacrolide antibiotics clarithromycin and erythromycin, and the azole antifungal agents fluconazole(Diflucan), itraconazole (Sporanox) and ketoconazole (Nizoral). Risk for rhabdomyolysis also may beincreased with concurrent use of other lipid lowering agents, cyclosporoine, certain calcium channelblockers (diltiazem (Cardizem), verapamil (Calan)) and protease inhibitors. Atorvastatin may alsoincrease the effect of levothyroxine (Synthroid).BRAND NAME: ZocorGENERIC NAME: simvastatinTHERAPEUTIC CATEGORY: HMG-CoA reductase inhibitorUSE: hypercholesterolemiaORAL COMPLICATIONS: taste alterationDRUG INTERACTIONS: The risk for myopathy/rhabdomyolysis is increased with concurrent use of themacrolide antibiotics clarithromycin and erythromycin, and the azole antifungal agents fluconazole,itraconazole and ketoconazole. Risk for rhabdomyolysis also may be increased with concurrent use ofother lipid lowering agents, cyclosporoine, certain calcium channel blockers and protease inhibitors. Theanticoagulant effect of warfarin may be increased by simvastatin.BRAND NAME: CrestorGENERIC NAME: rosuvastatin calciumTHERAPEUTIC CATEGORY: HMG-CoA reductase inhibitorUSE: used with dietary therapy for hyperlipidemias to reduce elevated total cholesterol, LDL-C,apolipoprotein B and triglycerides in patients with hypercholesterolemia and for treatment of familialhypercholesterolemiaORAL COMPLICATIONS: none 3
  • 24. DRUG INTERACTIONS: The anticoagulant effects of warfarin may be increased by rosuvastatin:monitor carefully. Rosuvastatin increases the serum concentrations of the hormonal contraceptivesethinyl estradiol and norgestrel. Concurrent administration of other cholesterol lowering medications(gemfibrozil, clofibrate, fenofibrate or niacin) may increase the risk for myopathy and rhabdomyolysis.Metal containing antacids may decrease the plasma concentratins of rosuvastatin: administer antacids atleast 2 hours after dosing. Bile acid sequestrants may reduce the absorption of rosuvastatin.HYPERTENSIONBRAND NAME: Prinivil, ZestrilGENERIC NAME: lisinoprilTHERAPEUTIC CATEGORY: ACE inhibitorUSE: hypertension, adjunctive therapy for congestive heart failure, post-MI if hemodynamically stableORAL COMPLICATIONS: xerostomia, dry cough, angioedemaDRUG INTERACTIONS: Increased risk for hypotension with alcohol, phenothiazines(antipsychotics)and probenecid. ACE inhibitors increase serum concentrations of digoxin, lithium andsulfonylureas (oral hypoglycemics). Increased risk for toxicity with potassium or potassium-sparingdiuretics. Diuretics have additive hypotensive effects when used with ACE inhibitors. Caution whenusing NSAIDS in patients with compromised renal function who are taking ACE inhibitors. NSAIDS,including high dose aspirin, may decrease the antihypertensive effects of ACE inhibitors. Antacidsdecrease the bioavailability of ACE inhibitors.BRAND NAME: Toprol-XLGENERIC NAME: metoprolol succinateTHERAPEUTIC CATEGORY: cardioselective beta blockerUSE: hypertension, angina, prevention of MI, atrial fibrillation; investigational for ventriculararrhythmias, migraines, essential tremors, aggressive behaviorORAL COMPLICATIONS: xerostomiaDRUG INTERACTIONS: Metoprolol may increase the effects of other drugs that slow AV conduction,alpha-blockers and alpha-adrenergic stimulants (eg. epinephrine). Epinephrine is safe to use in patientstaking cardioselective beta blockers (lowest dose, least concentration). NSAIDS (ibuprofen,indomethacin) used for greater than 3 weeks can decrease the antihypertensive effects of the drug. Theeffects of beta blockers are decreased with aluminum salts, calcium salts, barbituates, bile acidsequestrants (cholesterol-lowering drugs), NSAIDS, penicillins, rifampin and salicylates. Beta blockersmay decrease the effects of sulfonylureas (oral hypoglycemics), and may slow the metabolism oflidocaine. Increased hypotension and bradycardia may be observed with concurrent use of inhaledanesthetics and fentanyl derivatives.ADVERSE THROMBOEMBOLIC EVENTSBRAND NAME: PlavixGENERIC NAME: clopidogrelTHERAPEUTIC CATEGORY: antiplatelet agentUSE: reduce risk of atherosclerotic events in patients with history of recent MI, stroke, or establishedperipheral arterial disease; acute coronary syndrome (unstable angina)ORAL COMPLICATIONS: noneDRUG INTERACTIONS: Clopidogrel interfere with the metabolism of many medications, includingoral hypoglycemics, phenytoin and some NSAIDS, increasing risk for toxicity. Concurrent use ofclopidogrel with naproxen increases risk for GI bleeding. Anticoagulant medications taken withantiplatelet medications increases risk for bleeding. Atorvastatin (Lipitor) and macrolide antibiotics 4
  • 25. (clarithromycin, erythromycin) decrease the effects of clopidogrel. Many herbs interact with Plavix andincrease risk for bleeding: discontinue 14 days prior to surgery.ENDOCRINE DISORDERSBRAND NAME: SynthroidGENERIC NAME: levothyroxineTHERAPEUTIC CATEGORY: hormoneUSE: hypothyroidismORAL COMPLICATIONS: noneDRUG INTERACTIONS: Levothyroxine increases the effects of oral anticoagulants (Coumadin),causing an increased risk of bleeding. When taken together, toxicity may occur for both levothyroxineand tricyclic antidepressants (Elavil). Antacids containing aluminum and magnesium, iron, bile acidsequestrants (colestipol, cholestyramine), and the ulcer medication sucralfate (Carafate) decrease theabsorption of levothyroxine. Certain seizure medications (phenytoin, phenobarbitol and carbamazepine)and the TB medication rifampin (Rifadin) decrease levothyroxine levels. Levothyroxine may decreasethe effect of oral sulfonylureas.ANTIBIOTICSBRAND NAME: Amoxil, MoxatagGENERIC NAME: amoxicillinTHERAPEUTIC CATEGORY: antibioticUSE: infections of ear, skin, respiratory and urinary tracts; premedicationORAL COMPLICATIONS: oral candidiasis and black hairy tongueDRUG INTERACTIONS: Concomitant use of amoxicillin and erythromycin or amoxicillin andtetracycline is contraindicated. Amoxicillin may decrease the efficacy of oral contraceptives; therefore,patients should be instructed to use an alternative form of birth control while taking this antibiotic.Disulfiram (Antabuse), used to treat alcoholism, and the uric acid lowering agent probenecid (Benemid)cause increased levels of amoxicillin The effects of warfarin may be increased.BRAND NAME: AzaSite, Zithromax, ZmaxGENERIC NAME: azithromycinTHERAPEUTIC CATEGORY: macrolide antibioticUSE: orofacial and respiratory tract infections; middle ear infections, pharyngitis, strep throat, tonsillitis,pneumonia; premedicationORAL COMPLICATIONS: noneDRUG INTERACTIONS: Antacids containing aluminum or magnesium (Maalox, Mylanta) should notbe taken with azithromycin, as antacids decrease serum levels of the drug. Two hours should lapse priorto taking azithromycin following the use of an antacid. As with erythromycin, azithromycin interactswith many drugs, and may increase the levels of some antihistamines (Hismanal), cyclosporine(Sandimmune), carbamazepine (Tegretol), digoxin (Lanoxin), phenytoin (Dilantin), triazolam (Halcion),warfarin (Coumadin) and antiasthmatic drugs containing theophylline. Concomitant use of the macrolideantibiotics with the HMG Co-A reductase inhibitors increases the risk for rhabdomyolysis. Antibioticsdecrease the effectiveness of oral contraceptives. 5
  • 26. ANTIDEPRESSANTSBRAND NAME: LexaproGENERIC NAME: escitalopramTHERAPEUTIC CATEGORY: selective serotonin reuptake inhibitorUSE: major depressive disorder; generalized anxiety disorders (GAD)ORAL COMPLICATIONS: xerostomia, toothache, vomitingDRUG INTERACTIONS: Do not take this drug with MAOIs: fatal reactions have been reported.Combined use of this drug with other SSRIs and/or other classes of antidepressants increases risk forserotonin syndrome. Use of this drug with aspirin, NSAIDS and other drugs that alter coagulationincreases risk for bleeding. Systemic azole antifungals, ciprofloxacin, clarithromycin, diclofenac,doxycycline, erythromycin, and other CYP3A4 inhibitors may increase the levels and/or effects ofescitalopram. Avoid drinking alcohol with this medication. Combined use of SSRIs with sumatriptan(Imitrex) or other serotonin agonists may result in toxicity. CYP3A4 inducers may decrease thelevels/effects of escitalopram, including cabamazepine nafcillin, phenobarbital and phenytoin.BRAND NAME: OleptroGENERIC NAME: trazodoneTHERAPEUTIC CATEGORY: serotonin reuptake inhibitor/antagonistUSE: major depressive disorderORAL COMPLICATIONS: xerostomia, taste alterationDRUG INTERACTIONS: Sedative effects may be increased with alcohol and other CNS depressants;levels of trazodone may be increased by buspirone, SSRIs and venlafaxine. Trazodone may decreaselevels/effects of dabigatran. Avoid use of methylene blue (used to treat methemoglobinemia and UTI).GERD OR HYPERSECRETORY DISEASEBRAND NAME: NexiumGENERIC NAME: esomeprazoleTHERAPEUTIC CATEGORY: proton pump inhibitorUSE: short-term treatment of erosive esophagitis; symptomatic gastroesophageal reflux disease (GERD)ORAL COMPLICATIONS: xerostomiaDRUG INTERACTIONS: Esomeprazole may increase the levels of carbamazepine, statin drugs, andsome benzodiazepines (diazepam, midazolam, triazolam). Drugs in this class may decrease theabsorption of antiretroviral medications, iron, and systemic antifungal medications (itraconazole,ketoconazole). Esomeprazole may decrease the levels of phenytoin. Drug absorption is significantlydecreased (43%-53%) when taken with food; take at least 1 hour before meals.RESPIRATORY DISEASEBRAND NAME: SingulairGENERIC NAME: montelukastTHERAPEUTIC CATEGORY: leukotriene-receptor antagonistUSE: prophylaxis and chronic treatment of asthma; seasonal allergies; perennial allergic rhinitisORAL COMPLICATIONS: noneDRUG INTERACTIONS: Phenylketonuric patients should be informed that the chewable tablets containphenylalanine. Carbamazepine, phenobarbital, phenytoin, rifampin, and nafcillin may decrease the levelsof montelukast. St. John’s wort may also decrease the levels of montelukast. 6
  • 27. BRAND NAME: ProAir HFAGENERIC NAME: albuterolTHERAPEUTIC CATEGORY: beta 2-adrenergic agonistUSE: asthma, chronic obstructive pulmonary disorder (COPD)ORAL COMPLICATIONS: xerostomia, altered taste, vomiting, tooth discolorationDRUG INTERACTIONS: Increased toxicity (cardiovascular effects) is noted when albuterol isused with any of the following drugs: MAO inhibitors (Marplan, Nardil, Parnate), tricyclicantidepressants (Elavil), sympathomimetic agents (amphetamines, dopamine) and inhaledanesthetics(malignant arrhythmias). The effect of albuterol is decreased when used withnonselective beta blockers. When used with inhaled ipratropium (Atrovent), an increase in theduration of bronchodilation may occur.REFERENCES FOR TOP 20 MEDICATIONSTop 200 Medications for 2011. Source: IMS Health. Available at:http://www.pharmacytimes.com/publications/issue/2012/July2012/Top-200-Drugs-of-2011Physicians’ Desk Reference, ed. 65. Montvale, Medical Economics Co, Inc., 2011.Mycek MJ, Harvey RA, Champe PC: Lippincott’s Illustrated Reviews: Pharmacology. ed. 3.Philadelphia, Lippincott-Raven, 2006.Wynn RL, Meiller TF, Crossley HL. Drug Information Handbook in Dentistry. 18th ed. Hudson, Lexi-Comp Inc., 2012.Gage TW, Pickett FA. Mosby’s Dental Drug Reference. 7th ed. St. Louis, Mosby, Inc., 2005.Pickett FA, Terezhalmy GT. Dental Drug Reference with Clinical Implications. 2nd ed. Baltimore,Lippincott Williams & Wilkens, 2008.FDA WATCHES AND WARNINGSvarenicline (Chantix) FDA Safety Alert and Public Health Advisory Statement Patients should be provided with a medication guide highlighting neuropsychiatric symptoms receiving this medication Angioedema, serious skin reactions, visual impairment, accidental injury July 2011 – relabeling changes due to cardiovascular concerns; FDA is requiring manufacturer to conduct meta-analysis of clinical trials to examine risks: http://www.fda.gov/Drugs/DrugSafety/ucm259161.htm#safetyazithromycin, clarithromycin May be associated with liver failure 7
  • 28. tramadol (Ultram, Ultracet) FDA safety labeling revision Potential risk for potentially life-threatening serotonin syndrome Serotonin syndrome may occur with use of tramadol alone or with concurrent use of SSRIs, tricyclic antidepressants, MAOIs Adverse events may occur at recommended tramadol dose tramadol is indicated for moderate to moderately severe pain in adults for short-term use (≤5 days) for acute pain MANAGEMENT OF ORAL SIDE EFFECTS CAUSED BY MEDICATIONSFLUORIDE THERAPYFor caries control:Prescription fluorides for supplemental home use: 1.1% neutral sodium 5000 ppm Clinpro 5000 Anti-Cavity Toothpaste (3M ESPE), gel or dentifrice Prescription Control Rx (Discus Dental), Fluoridex Daily Defense Dentifrice and Gel (Discus Dental), NUPRO NuSolutions Toothpaste (Dentsply), Oral B Neutracare (P&G), PreviDent 5000 Booster toothpaste, PreviDent Gel, PreviDent 5000 Plus (Colgate), ProDenRx Dentifrice and Gel (Zila), Topex Take Home Care (Sultan Healthcare) 0.2% neutral sodium 920 ppm CaviRinse (3M ESPE), NaFrinse (Medical Products rinse Prescription Laboratory), Oral B Fluorinse (P&G), PreviDent Dental Rinse (Colgate), ProDenRx Rinse (Zila) 1.1% sodium and 5000 ppm Phos-Flur (Colgate) acidulated Prescription phosphate gel 0.4% stannous 1000 ppm Fluoridex Daily Defense Sensitivity Relief (Discus fluoride gel Dental); Gel-Kam Oral Rinse (Colgate), Kid Kare Plus 0.4% Stannous Fluoride Brush-on Dentifrice, Kids Kare 0.4% Stannous Fluoride Brush-on Gel (Zila), ProDenRx 0.4% Stannous Fluoride Brush-on Gel (Zila), Topex Take Home Care (Sultan Healthcare) 0.63% stannous 30 ml dose PerioMed (3M ESPE), Fluoridex Daily Renewal fluoride rinse dilution = 7 (Discus Dental) mg fl- ion and 22 mg stannous ion 8
  • 29. Over-the-counter supplemental fluorides for home use: 0.05% neutral sodium rinse 230 ppm Reach Act, Fluorigard, NaF rinse acidulated, NaF rinse neutral 0.044% sodium and 200 ppm Phos-Flur (Colgate); OrthoWash (3M ESPE) acidulated phosphate rinse 0.4% stannous fluoride gel 1000 Gel-Kam Treatment Gel (Colgate), Just For Kids ppm (3M ESPE), Omni Gel (3M ESPE), Oral B Stop (P&G) 0.0221% sodium fluoride Listerine Total Care, Listerine Smart Rinse (J&J)Fluoride Varnishes: 22,600 PPM sodium fluoride5% sodium fluoride varnish varnish in AllSolutions (Dentsply)(in-office use only) a tube or Duraphat (Colgate) single- Duraflor (A.R. Medicom) unit dose Enamel Pro Varnish with ACP (Premier) dispensers FluoroDose (Centrix) Fluoridex Lasting Defense (Discus Dental) Prevident (Colgate) Profluorid Varnish (VOCO) Vanish (Omni/3M EPSE) VarnishAmerica with xylitol (Medical Products Laboratories) Vella with xylitol (Preventech) Waterpik UltraThin (Teledyne)SALIVARY REPLACEMENT THERAPY1. OTC Artificial Saliva Preparations: PRODUCT Entertainer’s Secret® Moi-Stir® Mouthkote® Salivart® Salix® -carboxymethylcellulose = gives feeling of viscosity -relief while product is in contact with the tissues; convenience -some contain preservatives: parabens (PABA) = allergy potential2. Biotene product line (GlaxoSmithKline): toothpaste, oral gel, mouthrinse, chewing gum -contain 3 key salivary enzymes found in natural saliva; sodium fluoride, xylitol3. Orajel product line (Del Pharmaceuticals, Inc.): dry mouth moisturizing gel and spray - moisturizing gel and spray -18% glycerin; -sorbitol (gel); xylitol (spray) -moisturizing toothpaste -thione antioxidant complex; sodium monofluorophosphate (0.18% w/v fluoride ion) -sugar-free; sorbitol, xylitol; no sodium lauryl sulfate 9
  • 30. 4. Oasis (Oasis Consumer Healthcare) -mouthwash or mouth spray -“TriHydra” technology: hydrophilic polymers, xanthum gum, glycerine and carboxymethylcellulose; relieves symptoms for up to 2 hours5. GC Dry Mouth Gel (GC America) -alcohol free, sugar free, neutral pH, applied as needed6. Salese (Nuvora) -lozenge with water absorbing polymer plus xylitol; raises pH; Dentiva: antimicrobial7. Colgate Dry Mouth Relief Mouthrinse (Colgate Oral Pharmaceuticals) -fluoride mouthrinse (0.02% sodium fluoride = 90 ppm); tri-polymer system to help coat soft tissues; moisture retention; alcohol free; soothing, mild flavor8. Two prescription drugs now available to stimulate salivary flow: Salagen (5 mg pilocarpine hydrochloride) -cholinergic agonist that stimulates muscarinic acetylcholine receptors in the salivary glands to increase serous salivary flow. -need to take the drug for a minimum of 90 days to see optimum effects -contraindicated if known hypersensitivity to the drug, uncontrolled asthma or narrow-angle glaucoma -drug interactions associated with pilocarpine include anticholinergic medications (eg. antiparkinsonion drugs, carbamazepine, digoxin, sedative antihistamines, tricyclic antidepressants), cholinergic medications (eg. antiglaucoma drugs) and beta-adrenergic blocking drugs -indicated for radiation therapy patients and Sjogren’s syndrome - dosage: for radiation therapy patients: - 5 mg tid (15-30 mg per day); 12 weeks of therapy - dosage: for Sjogren’s patients: - 5 mg qid; efficacy has been established after 6 weeks of use Evoxac (cevimeline) -cholinergic agonist used to treat xerostomia in patients with Sjogren’s syndrome - dosage: 30 mg tid -contraindications: hypersensitivity to drug or any of its components, uncontrolled asthma, narrow-angle glaucoma, acute iritis, conditions where miosis is undesirable -use with caution in patients with CV disease, asthma, COPD, decreased visual acuity, the elderly, or in those with kidney problemsANTIMICROBIALS -an important adjunct in managing the oral complications of xerostomia -reduce plaque formation, and to prevent or reduce the severity of gingivitis -promotes a healthy oral ecosystem -OTC and prescription antimicrobials available on the market from which to choose -3 FDA and ADA approved antimicrobials: chlorhexidine, Listerine® and triclosan (Colgate® Total) - Other agents available as mouthrinses exhibit antibacterial properties, but do not possess good substantivity: -stannous fluoride = antibacterial. carioprotective and desensitizing effects 10
  • 31. -cetylpyridinium chloride = rupture bacterial cell walls and alter cytoplasmic contents; bind strongly to plaque and tooth surfaces (Cepacol®, Scope®, Advanced Formula Viadent®; alcohol free: Crest® Pro Health Rinse, BreathRx) -Crest Pro Health Rinse with CPC has data to support 12 hour substantivity = vehicle improves bioavailability -oxygenating agents = damage bacteria by altering cell membrane permeability -Natural Dentist® Health Gums Moisturizing Antigingivitis Mouthrinse -contains all natural formulation -germ kill of 40 oral pathogens, including Strep mutans and some red complex -comparable to Listerine® in terms of pathogen reduction -4 published clinical trials and MIC laboratory data to support efficacy -Triclosan (Colgate® Total toothpaste) -antimicrobial agent in dentifrice form = decreases plaque viability -both antimicrobial and anti-inflammatory properties -unique technology of delivery mode: PVM/MA copolymer = GANTREZ -copolymer allows binding to surfaces with slow release; promotes adhesion/uptake of triclosan on enamel, plaque and soft tissue -triclosan: broad spectrum, substantive to 12 hours -over 75 clinical trials to support safety and efficacy of Colgate® Total -anti-inflammatory effect: dampens stimulation of the production of IL1- beta and TNF alpha = inflammatory mediators (cytokines) that destroy tissue and bone = local host modulation -Crest® Pro Health dentifrice -stannous fluoride multi-care dentifrice -older formulations: adverse taste and staining effects; instable in aqueous solutions -0.454% stabilized stannous fluoride with sodium hexametaphosphate -sodium hexametaphosphate = pyrophosphonate (anti-calculus/anti- staining) -polymer of repeated pyrophosphate subunits -stronger affinity to calcium hydroxyapatite in enamel and dentin -greater prevention of crystallization at enamel surface (calculus prevention) and adsorption of stains from chromogens (staining) - silica-based low-water dentifrice to reduce hydrolysis of sodium hexametaphosphate and to maintain effective pyrophosphate levels -12 hour substantivitiyImportant take home messages with antimicrobials:- chlorhexidine and CPC are cations: drug reactions with SLS and fluoride = wait 30 minutesafter brushing or vigorously remove all toothpaste residue before rinsing- chlorhexidine and Listerine have been shown to kill 7 species of Candida- chlorhexidine and Listerine kill multiple species of Strep: Strep mutans 11
  • 32. - chlorhexidine and Listerine have been shown to reduce incidence and severity of aphthousulcersANTIFUNGALS - fungal infections occur as a result of alterations in oral flora, immunosuppression and underlying systemic disease (diabetes, xerostomia, anemia, chemo, inhaled steroids) - opportunistic infections - clinical presentation: - pseudomembranous appearance (bright red with overlying white pseudomembrane); atrophic appearance (tongue); hyperkeratotic appearance (denture stomatitis); symptomatic geographic tongue; angular cheilitis -drug therapy includes topical and systemic medications depending upon the extent and severity of the infection. -azole antifungals are used to treat chronic, extensive mucocutaneous candidiasis -polyenes are used to treat local candidiasis (topicals) -antifungals are being used in combination with corticosteroids, such as nystatin and triamcinolone, to treat both the fungal infection and the inflammation of angular cheilitis - medications must be used for a minimum of 48 hours after the disappearance of clinical signs and symptoms; re-evaluate condition 14 days after therapy has been completed - efficacy of topical drugs is dependent upon contact with the lesions - some topical preparations contain sugar - may choose to prescribe vaginal preparation - in addition to antifungals, consider chlorhexidine or essential oil mouthrinses for long term prevention - prescription antifungals for systemic use if patient is refractory to topicals: *cautions: liver function and multiple drug interactionsTopical Antifungal Medications: nystatin ointment apply thin coat to affected area (or inner surface of denture) 4-5 times per day Mycelex ® 10 mg troches disp: 70 troches; dissolve 1 troche in mouth 5 times per day until (clotrimazole) gone; leave any prosthesis out during treatment and soak prosthesis in nystatin liquid suspension overnight Nizoral® 2% cream apply thin coat to affect areas (or to inner surface of denture) after (ketoconazole) meals iodoquinol and hydrocortisone apply locally to affected area 3-4 times per day for 10 days to 2 cream weeks, then re-evaluate nystatin and triamcinolone apply locally to affected area 4 times per day for 10 days to 3 weeks acetonide ointment and then re-evaluateTopical nystatin: - is well-tolerated, non-sensitizing - soak dentures in nystatin suspension overnight - nystatin ointment can be placed in denture and worn during day (like an adhesive) 12
  • 33. Systemic Azole Antifungal Medications: Diflucan® fluconazole Take 2 tablets on day 1, then 1 tablet daily for 14 days until gone 100 mg tablets *a shorter course may be adequate; extensive infection may require second course of treatment Nizoral® ketoconazole Take 1 tablet daily with a meal for 14 days 200 mg *may cause irreversible liver damage with long-term use (greater than 3 weeks)ANTIVIRALS - viral infections: acute onset of symptoms - vesicular eruption of soft tissues - rupture of vesicles leaves ulcerations - ulcerations are generally small in size - if left untreated, ulcerations coalesce to form large lesions - primary infection can present as: gingivostomatitis, recurrent lip lesions (herpes labialis), intraoral ulcers (recurrent intraoral herpes) that involve oral/perioral tissues - primary infection is systemic that leads to acute gingivostomatitis involving multiple tissues: buccal mucosa, lips, tongue, floor of mouth, gingiva - management of viral infections is generally palliative (although acyclovir is now used for prevention of primary infections) - treatment of primary infections includes combination therapy: - acyclovir - topical anesthetic rinses (eg. Benadryl, Xylocaine viscous, OTC benzocaine products ) - fluids, vitamins and mineral supplements and restAntiviral Medications for Herpes Simplex: Zovirax® 200 mg tablets acyclovir take 1 capsule 5 times per day for 10 days or 2 capsules 3 times per day for 10 days Zovirax® ointment 5% acyclovir apply q 3 hours (6 times/day) for 7 days Denavir® cream 10mg/g penciclovir apply every 2 hours (lips and face only) for 4 days (1%) Valtrex® 500 mg valacyclovir 2 grams twice daily for 1 day at prodrome (separate doses by 12 hours) Abreva (OTC) docosanol 10% apply locally as directed 5 times per day; start at prodrome and continue for 4 days; do not apply directly to inside of mouth or around eyes Viroxyn® (OTC) alcohol/benzalkonium single dose applicator/vial; at prodrome, rub chloride medication into lesion until medication is gone (10 seconds)ORAL ULCERATIONS (NON-VIRAL) AND PAIN CONTROL -Recurrent Aphthous Stomatitis: - patients with recurrent aphthous should be evaluated for iron, folic acid and/or vitamin B12 deficiency - severe recurrent aphthous may be treated with an oral suspension of tetracycline 13
  • 34. - regular use of Listerine has been shown to reduce the frequency, duration and severity of lesions; chlorhexidine has been shown to reduce duration of lesions -localized ulcerations: - OTC topical anesthetic agents containing benzocaine in protective preparations - Benzocaine and tetracaine (Viractin) are esther anesthetics; therefore, caution must be used when recommending these OTC products to clients with reported allergies to anesthetics or to PABA - Debacterol (sulfonated phenolics in aqueous solution) – therapeutic cauterization - dry ulcer, apply directly to lesion, keep in contact for 5-10 seconds; (larger lesions may need up to 2 minutes); rinse immediately, and expectorate with water -generalized oral pain: - OTC agent such as Chloraseptic® spray - prescription mouthrinse Xylocaine ® 2% (viscous lidocaine) - Benadryl® elixir and Benylin® cough syrup -severe pain, such as that associated with mucositis: - anesthetic agents may be mixed with OTC coating agents to provide lubrication and relief from pain - Benadryl® elixir added in equal amounts to Maalox®, Mylanta® or Kaopectate® - sucralfate (Carafate®), the prescription medication used to treat duodenal ulcers, may be prepared as a 1 gm/15 mL suspension for use in this population as well. (A pharmacist should be consulted to assist with the preparation of oral suspensions.) -dry, cracked lips: topical water-based product; Oral Balance®Topical prescription agents for aphthous lesions: amlexanox oral paste 5% Apthasol® apply 4 times per day (after meals and at bedtime) until area heals triamcinolone acetonide Oralone®0.1%; Kenalog in apply after each meal and at Dental Paste Orabase® 0.1% bedtime chlorhexidine oral rinse Peridex®, PerioGard® rinse with 20 ml for 30 sec tid fluocinonide 0.05% Lidex® ointment mixed 50/50 apply thin layer to oral lesions 4 (used for oral inflammatory with Orabase (30 grams total) times per day lesions that do not respond to Kenalog in Orabase®) clobetasol propionate 0.05% Temovate® apply small quantity with a cotton tip applicator to affected area 3-4 times daily betamethasone 0.1% ointment apply small quantity with a cotton tip applicator to affected area 3-4 times daily dexamethasone elixir Decadron® rinse with 1 teaspoon for 2 0.5 mg/5 mL minutes 4 times per day and expectorate 14
  • 35. Topical OTC agents for aphthous/pain control: Benzyl alcohol Zilactin® Gel apply q 3-4 hours Benzocaine 10% Zilactin® B apply q 3-4 hours Lidocaine 2.5% Zilactin L apply q 3-4 hours Diphenhydramine Benadryl® Elixir swish with 1 tsp for 2 min before each meal (can be used as a swish and swallow) Benzocaine, gelatin, pectin and Orabase® with Benzocaine apply 3-4 times/day sodium carboxymethylcellulose Tetracaine Hydrochloride 1% Viractin® apply 3-4 times/day up to 7 days 15