Significance of drugs in Oral Diagnosis

Culeen Barapon

• Dental practice is complicated by the many drugs that are prescribed in the practice of medicine in as much as those drugs may produce unwanted side effects that interfere with dental treatment or may interact with drugs used in dental treatment.

• The need to obtain a complete history of drugs being taken by a dental patient and to review the drugs’ actions, side effects, and interactions is clear.

• The major concern in dental practice is the suppression of corticotropin and the ensuing reduced activity of the adrenal cortex.

• Dental patients are exposed to stress in the form of anxiety, trauma, infection, and surgery. Adrenocortical suppression reduces or eliminates a patient’s ability to respond physiologically to stressful stimuli, therefore requiring supplemental doses of steroid to be administered before stressful dental appointments or when conditions arise that cause stress.

Adrenocorticosteroids

• Other side effects of steroid therapy that are important to the dentist are: the interference with fibroblastic activity, reduced inflammatory response, antiinsulin effect, and increased gluconeogenesis.

• Prolonged high doses of steroids within 2 years may require that a booster dose be given to prevent adverse reaction to stress.

Adrenocorticosteroids

• Ibuprofen, benoprofen, zomepirac, and mefenamic acid are prescribed extensively for arthritic pain and for mild to moderate postoperative dental pain.

• The mild analgesics may enhance the effect of oral anticoagulants, resulting in risk of serious postoperative hemorrhage.

Analgesics

• Among the moderate analgesics in popular use propoxyphene has a high potential for abuse.

• The narcotics such as meperidine, oxycodone, hydromorphone, and morphine share the common side effect of respiratory depression and have a high potential for abuse.

Analgesics

• A large number of women are given these drugs to correct a reduction in hemoglobin or RBC count. They are also used in the treatment of pernicious anemia.

• The types used as antianemic drugs are iron compounds, vitamin B12, folic acid and liver extract.

• The iron compounds may produce teeth pigmentation if given in liquid form. The solution are usually acidic and may enhance caries activity.

Antianemic compounds

• Rapid-acting nitrites have been used for years to relieve angina pectoris. Nitroglycerin is in widest use.

• Propranolol, a beta-blocking agent, causes bronchial constriction and may precipitate heart failure. It has an additive effect on general anesthetics and interacts with several drugs – barbiturates, chlorpromazine, and lidocaine.

• Use the minimum available concentration of vasoconstrictor in local anesthetics.

Antianginal agents

• Drowsiness is the chief side effect of sedatives, although dryness of the mouth may accompany diazepam.

• Antipsychotic agents such as chlorpromazine may cause side effects like sedation and dry mouth.

• It may be helpful for patients distressed by dry mouth to have prescribed for them a moistening agent for the mouth such as saliva substitute or a noncariogenic agent to encourage salivary flow.

Antianxiety agents

• Quinidine, procainamide, phenytoin, and propranolol are drugs frequently used to control tachycardia, atrial flutter, atrial fibrillation, or premature contractions.

•Cardiac stimulants such as caffeine in aspirin compound or the vasoconstrictor in local anesthetic may initiate an arrythmia and should be used with caution in patients taking these drugs.

• Thrombocytopenia is associated with quinidine. Gingival enlargement may be related to treatment with phenytoin.

Antiarrhythmic drugs

• Prolonged antibiotic therapy encourages a change in oral flora, which may encourage the overgrowth of Candida albicans and infection of the oral mucosa.

• Some antibiotics produce serious side effects such as depression of bone marrow that has been related to therapy with chloramphenicol.

Antibiotics

• Membranous colitis has been attributed to the use of clindamycin and lincomycin.

• A history of continuous penicillin therapy to prevent recurrent rheumatic fever is an indication to modify the regimen from penicillin to erythromycin to prevent bacterial endocarditis.

Antibiotics

• Heparin and coumarin derivatives are in popular use for control of thromboembolic disease such as thrmobophlebitis, cerebrovascular disease, and cardiovascular disease. They are also required in persons with a valvular prosthesis.

• The risk of altering the level of antiocoagulation to accommodate surgery must be weighed against the urgency of the surgery and the possiblity of local control of bleeding.

Anticoagulants

• Different drugs are used for different types of seizures, although phenytoin (Dilantin), carbamazepine (Tegretol), diazepam (Valium), and phenobarbital are widely used individually or in combination for management of partial and generalized seizures.

• Additional sedation may be advisable depending upon the past experience of the patient, and the dosage must be adjusted accordingly.

• The major well-known side effect of phenytoin is gingival enlargement.

Anticonvulsants

• Tricyclic antidepressants are in frequent use for management of mild endogenous depression in ambulatory patients.

• Tricyclic antidepressants cause dry mouth and potentiate the effects of epinephrine and other sympathomimetic amines in local anesthetics.

• Meperidine should be avoided altogether and the dosage of the other narcotics reduced by one fourth if needed for control of severe dental pain.

Antidepressants

• Allopurinol, probenecid, sulfinpyrazone, and ticrynafen are uricosuric agents used in the management of persons with gout.

• Probenecid and ticrynafen inhibit the excretion of penicillin, prolonging the blood level produced by each dose of the antibiotics.

• Aspirin inhibits the action of these drugs.

Antigout medications

• Two side effects of antihistamines are important in dental practice, sedation and anticholinergic effect.

• Caries susceptibility and increased predisposition to candidiasis are of concern to the dentist in the management of patients receiving long-term antihistamines.

Antihistamines

• Chemotherapeutic agents used in the treatment of cancer are alkylating agents, antimetabolites, antibiotics, and other types of chemical agents.

• Most causes significant depression of bone marrow with resulting leukopenia and thrombocytopenia.

• There are two aspects to dental care of patients treated with these drug groups: (1) constant awareness of complete blood count (2) managing the stomatitis that these drugs produce.Antineoplastics

and Immunosuppressants

• Commonly used drugs are atropine, belladonna, hyoscyamine, and propantheline.

• The most important side effect of these drugs of concern in dental practice is dryness of the mouth caused by anticholinergic effect of the drugs on salivary glands.

• Caries control by dietary restriction of cariogenic agents and by the application of topical fluorides may be indicated when the dry mouth is profound and prolonged.

Antispasmodics

•The drugs in use are diuretics, sympathetic depressants, vasodilators, and angiotensin antagonists.

• The side effect of diuretics that concerns the dentists is dry mouth.

• Several of the antihypertensive agents cause postural hypotension.

• Control of factors that tend to elevate blood pressure during dental appointment is advisable.

Antihypertensives

• The bronchial dilators are used for the treatment of bronchial asthma and emphysema.

• Those most often used are adrenergic agents, isoproterenol, theophylline, and corticosteroids.

• Tachycardia may be intensified by the administration of local anesthetics. CNS stimulation may also be enhanced by the use of local anesthetics.

Bronchial dilators

• They are used as primary and adjunctive treatment in hypertension and congestive heart failure. They are also used in renal failure, glaucoma, and various forms of edema.

• The chief concern in dental practice for patients receiving long-term diuretic therapy is dry mouth and its consequent discomfort and increased susceptibility to dental caries.

• Potassium-sparing diuretics have the potential side effect of hyperkalemia and cardiac arrythmia, which might be influenced by vasoconstrictors in local anesthetics.Diuretics

• These agents are used to alter the biologic effect of internally produced hormones for the purpose of controlling a pathologic process or correcting an imbalance or for contraception.

• Postmenopausal reduction in estrogen may be related to oral complaints of “burning mouth” and mucosal atrophy, although the results of treatment with exogenous estrogen are unpredictable.

Estrogens, progesterones, progestins

• There are combinations containing barbiturates such as butalbital (Fioranal) and hyoscyamine (Donnatal) that are frequently prescribed for long-term intermittent use.

• The central depressant effect of barbiturates can be potentiated by narcotics used for pain control, resulting in respiratory depression as well as loss of judgment and coordination.

Sedatives and Hypnotics

Thank you!

Source:Oral Diagnosis. Kerr, Ash, Millard