November 2013, Volume 9, Issue 11
Published by AEGIS Communications
Does Dentistry Have A Pill Problem?
Today’s older dental patients differ from their counterparts of 30 years ago in some important ways. Many older patients are in better oral health than earlier generations were and retain more of their teeth. These patients need more complex periodontal and implant procedures performed in their later years.1
These same older patients are also less likely to be satisfied with dentures and want to do whatever is possible to improve and maintain a good quality of life. Because today’s seniors are living longer, it often makes sense for them to get dental implants in their seventies and eighties. This new reality means that dentists today face challenges treating older patients, who often present with one or more chronic health conditions and may be taking multiple medications to treat them.
It is projected that the portion of the US population older than 65 years will increase from 14% in 2011 to more than 20% by 2030.2 This means that most dentists will be caring for more elderly patients in their practices. The issue of polypharmacy—the concurrent use of multiple medications—has become a serious management issue for dentists in all areas of practice, but especially for dentists with elderly patients.
With the availability of more than 15,000 currently approved prescription and nonprescription drug products and thousands of herbal and dietary supplements, keeping up with the sheer amount of drug information is a Sisyphean feat.3 This task is especially true for those who treat elderly patients. In the United States today, people older than 65 years represent approximately 14% of the population, but they take about two thirds of all prescription medications—largely because older people are more likely to be living with one or more chronic conditions that require multiple prescription and nonprescription treatments (Table 14).5 Polypharmacy is the norm in this age group; the average person older than 64 years regularly takes 4 to 5 different medications.3,6
How Does Polypharmacy Affect Dentistry?
“You have two issues going on,” explains Marc Heft, DMD, PhD, director of the Claude D. Pepper Center for Research on Oral Health in Aging in Gainesville, Florida. “The elderly are taking more medicines, so there is a greater potential for drug interactions, and you also have potential changes within organ systems [such as declines in renal, liver, pulmonary, and cardiac function] that might affect how the drugs are handled.” The elderly also experience reduced homeostatic competence and a decline in immune response.1 Table 2 further explains the ways that aging impacts how certain drugs are metabolized.
Many elderly patients undergo dental procedures requiring local anesthesics, vasoconstrictors, analgesics, and antibiotics. In using and prescribing these medications, dentists have to be careful that the drugs don’t interact with the many medications, supplements, and nonprescription drugs that many elderly patients are already taking to treat chronic diseases.
According to the American Society of Consulting Pharmacists (ASCP), the impact of medication-related problems in persons older than 65 years now rivals that of Alzheimer’s disease, cancer, cardiovascular disease, and diabetes.7 “Medication-related problems are estimated to be one of the top five causes of death in that age group and a major cause of confusion, depression, falls, disability, and loss of independence,” the ASCP states.
A Medical History: The Best Tool
Getting an accurate, up-to-date medical history is the first step in the process of preventing medication-related problems in all patients, especially the elderly. “The most important thing you can do for your patient is take a good history,” says Michael A. Siegel, DDS, MS, FDS RCSEd, professor and chair of Oral Medicine and Diagnostic Sciences at the College of Dental Medicine at Nova Southeastern University in Fort Lauderdale, Florida.
Taking a careful history and keeping it up to date can be difficult to accomplish in a busy, real-world dentistry practice. The dentist may not have access to a truly complete patient history for many reasons, beginning with unreliable reporting, especially in older patients, who may be confused, forgetful, unaware of all their health issues and medications. But there are steps all dentists can take to make the patient history more reliable.
Most dentists ask patients to bring a complete list of the medications currently taken, including supplements and over-the-counter medications. If that is not possible, a spouse or child can accompany the patient and tell the dentist what should be included in the history. Dr. Siegel asks his patients to make an expansive list. “My approach is ‘you are what you eat.’ Anything that patient puts in his or her body affects me somehow,” he says.
Allen Ali Nasseh, DDS, MMSc, an endodontist and president of RealWorldEndo (http://realworldendo.com) in Boston, Massachusetts, suggests that prior to the appointment, the front desk staff contact the patient and communicate the importance of bringing a full list of medications with them so they don’t end up forgetting the names and dosages of medications when they are at the office and filling out the history. “There are many online and print sources for practitioners to easily access information about any contraindications, interactions, etc, that they may need to be concerned with,” he says. This also applies to alternative medications the patient is taking.
The first thing to take care of when a patient comes to the office is the medical history, agrees Louis Rose, DDS, MD, a periodontist who teaches at the University of Pennsylvania School of Dental Medicine and is in private practice in Philadelphia. “You don’t know if the history you’re getting is totally accurate, but there are ways of taking a history that make it more likely,” he says. Most dentists ask questions followed by lines of yes/no responses. “That really doesn’t tell you much,” Dr. Rose says. If you see something suspicious like a “no” response to the question about having cardiac problems, but then you see the patient has written that she’s taking cardiac drugs, you have to discuss this. If the patient doesn’t remember what drugs he or she is taking, the dentist is obligated to find out either by calling the physician or insisting the patient provide the correct information before treatment is performed, says Dr. Rose.
In elderly patients, it is critical to continually update the medical history because health conditions in this age group tend to change rapidly from appointment to appointment. Attention should especially be directed to changes in medications. Then a determination has to be made as to whether the patient, either due to compliance or economics, is actually following their doctors’ prescriptions, says Morton Rosenberg, DMD, professor of Oral and Maxillofacial Surgery, head of the Division of Anesthesia and Pain Control, Tufts University School of Dental Medicine and associate professor of Anesthesiology at Tufts University School of Medicine in Boston.
Dr. Heft encourages his students to think of the process of reviewing elderly patients’ medical histories as an opportunity to be an effective case manager. Not only do older patients consume more medications and have more office visits, but they often have multiple providers. “You will find that when you’re getting a patient’s health history or medication list, often you will see redundant drug classes,” he says. “We dentists have a unique opportunity because our patients come back routinely,” he says.
Looking at the issue of a complete medical history from a risk-management perspective, The Dentists Insurance Company (TDIC) advises that dentists use a medical form specific to the elderly—something only 6% of dentists currently use.8 TDIC encourages dentists to allow extra time to thoroughly discuss the patient’s history, talk to the elderly patient’s physician prior to performing invasive treatments, and document all discussions with other practitioners.
It’s important for the dentist to understand what’s going on, and not to be shy about contacting physicians to get an updated health history for the patient.
Dr. Heft advises that dentists look for a cause when a previously stable patient suddenly has caries, such as a change in medications or health status, for example, and have a conversation with their doctor.
A common scenario occurs when a patient with atrial fibrillation needs implants. The dentist will want to know if the patient is on blood thinners, and will need to contact the patient’s physician to find out at what level the anticoagulant is functioning. “Is it above 3.5, below 3.5?” Dr. Rose asks. “Find out and make a decision. The dentist is the one who is responsible if something happens during surgery.”
“If you are treating elderly patients, you have to have a good relationship with their physician,” Dr. Siegel agrees.
After the preliminary examination, the dentist has to decide whether the patient’s primary care doctor or specialist should be contacted for further clarification. Contacting patients’ physicians may be the last remaining stronghold of the fax machine, notes Paul A. Moore, DMD, PhD, MPH, professor of Pharmacology and Dental Public Health, and chair of the Department of Dental Anesthesiology at the University of Pittsburgh School of Dental Medicine. “The fax industry probably gets half its income from communications between dentists and physicians.”
Medications in Dentistry: The Concerns
“On the whole, drugs used in dentistry are very safe, and we use them for a limited amount of time,” Dr. Moore says. “The greatest concern dentists should have when it comes to elderly patients is what their medical status is, what diseases they have.” Dr. Nasseh also stresses that while the majority of the time no alterations are needed in the dentist’s medication plan, it is important have complete information about what medications the patient is taking, especially when it is a collection of drugs for a collection of disorders. The cardiovascular drugs—particularly drugs for hypertension and blood thinners—present the most concern, according to Dr. Nasseh, especially if surgical procedures are performed. However, in dentistry, he says, the postoperative use and abuse of antibiotics and painkillers is a bigger issue.
Some common medications prescribed by dentists—particularly antibiotics/antimicrobials, analgesics, anesthetics—can potentially cause interactions and toxicities in elderly patients.
Clarithromycin can have potentially serious interactions with drugs commonly prescribed for cardiovascular conditions. A recent large Swedish study showed that clarithromycin raised the concentration of simvastatin 10-fold when taken concurrently; it also increases digoxin levels.9 Clarithromycin is one of many drugs affected by the cytochrome P450 system (see below), with potentially serious results.
Cephalosporins impair clotting mechanisms and can cause bleeding problems.1
Opioid analgesics present one of the greatest concerns because they can cause respiratory depression in the elderly. Opioids can cause dizziness, increasing the risk of falls and broken hips. Physicians may have prescribed narcotics for chronic pain conditions, so dentists should pay particular attention to what analgesics patients may already be taking. Older adults are more sensitive to the depressant effect of drugs, so the dentist may find it necessary to reduce the dosage of analgesics, antianxiety drugs, sedative/hypnotics, and general anesthetics.1 Dentists administering sedatives have to be aware of patients with histories of alcohol and/or drug abuse, not only because of possible interactions but also because of their long-term effects on major organ systems, Dr. Rosenberg notes. “The elderly population is no different from the younger population as far as the scope of these problems and the importance of understanding their clinical implications,” he says.
Nonsteroidal anti-inflammatory drugs (NSAIDs) are associated with compromised renal or gastrointestinal function and hypertension. Many older patients are taking NSAIDs for painful chronic conditions, so when analgesics are prescribed for management of postoperative pain, it’s important to be aware of what other analgesics patients are taking. In addition, dentists should also be concerned about prescribing NSAIDs for patients on warfarin. NSAIDs inhibit platelet aggregation and warfarin inhibits blood clotting. Taking both together creates a danger of bleeding.
“Pushing” the dose of epinephrine is of concern in patients who are using nonselective beta-blockers (eg, propranolol, nadalol, timolol, sotalol), cautions Elliot V. Hersh, DMD, MS, PhD, professor of Pharmacology at the University of Pennsylvania School of Dental Medicine in Philadelphia. Case reports show that pushing the epinephrine dose to more than 2 cartridges/carpules (more than 0.036 mg) can result in severe hypertension and bradycardia. “As a general rule, no more than two carpules containing 1:100,00 epinephrine (0.036 mg) should be used during any dental appointment for older adults with cardiovascular disease,” Dr. Siegel states. At this dosage, hemodynamic effects are negligible, as it localizes the anesthetic, ensuring it lasts longer and is more profound. “Epinephrine is our friend” when used this way, says Dr. Siegel, because the little bit that is being given prevents a surge of the patient’s adrenaline, which can wreak havoc. Considering how often vasoconstrictors are used in dentistry, reports of serious drug interactions involving them are, fortunately, quite rare. This may be because the systemic effects of epinephrine are short-lived and its potential pressor effects are limited by opposing vasodilatory properties.10
cyp450 Enzyme lnhibitors & inducers
Many drugs rely on the hepatic and intestinal cytochrome P450 enzyme system for biotransformation.10 It’s very important to understand the great reach of this enzyme system and the potential for severe drug interactions that it can cause, cautions Dr. Hersh. There are drugs that block and drugs that induce CYP450. “The most significant drug interactions involve medications that block the activity of the CYP450 system,” he says. “Blockage of these enzymes can cause levels of the drug to build up and become toxic rather than clear properly.” Erythromycin and clarithromycin are potent inhibitors of one of the CYP450 isoenzymes, and can interact with benzodiazepines used in dentistry as oral and injectable anxiolytics. The result can be benzodiazepine accumulation and prolonged or excessive sedation.
Dr. Hersh points to risks involving warfarin. “Many dentists are not aware that the antimicrobials metronidazole, fluconazole, and clotrimazole can elevate warfarin levels in patients,” he notes. Because warfarin has a low therapeutic index, it only works properly within a very tight range. If the patient is not in the therapeutic range, serious adverse drug interaction and bleeding can result.
Corticosteroids like methylprednisolone, given to reduce postoperative swelling, are used to treat many chronic inflammatory and autoimmune diseases. If the dentist prescribes erythromycin, clarithromycin, or azole antifungals, there is a potential for an elevation of corticosteroid levels—and subsequently corticosteroid toxicity, unwanted immunosuppression and suppression of the hypothalamic-pituitary-adrenal axis, and hyperglycemia.11
Two other potentially serious adverse effects from common prescription medications, xerostomia and osteonecrosis of the jaw, are addressed in Table 312,13.
Nonprescription Drugs and Supplements
No discussion of polypharmacy-related issues would be complete without including the significance of nonprescription drugs and supplements. “Many patients don’t realize that some alternative treatments and products are not necessarily without risk, and many don’t report them in health histories, even though they may, in fact, have direct clinical consequences during the course of their dental care,” Dr. Rosenberg states.
Dr. Rose points out that fish oil is supposed to be great for the heart, but if the supplement is taken daily, patients need to know that it can interfere with blood clotting. “Patients don’t realize that even the smallest of surgical procedures can be affected by taking this supplement,” he warns.
The following popular herbal supplements are known to interact with these common medications14:
• Echinacea is known to cause liver toxicity and should not be used with medications that affect the liver, such as ketoconazole.
• St. John’s wort should not be taken with medications such as tetracycline, which increase sun sensitivity, or the selective serotonin reuptake inhibitors, because they can cause dizziness and agitation when taken together.
• Feverfew can impair the action of platelets and should be avoided in patients taking warfarin.
• Ginkgo biloba also has blood-thinning properties and should not be taken with NSAIDs, aspirin, naproxen, or anticoagulants.
Given the number of medications many elderly people have to keep track of daily, and the challenging health issues with which they may be living, elderly patients’ ability to follow directions is an issue. “They are more likely to misuse prescribed drugs because of confusion, poor vision and hearing, and dementia,” Dr. Siegel says. In the United States, an estimated 15 million older adults report some type of disability in hearing, vision, cognition, ambulation, and self-care.7 Elderly patients may omit medications, take them out of sequence, or forget to take them with (or without) food as directed. He suggests several simple but effective steps when prescribing medications for the elderly:
• Write “label large” on every prescription so that the pharmacist uses a larger bottle for the pills and prints the label in an 18 font instead of 10. “It’s a simple thing to do and the patient can read the bottle better,” Dr. Siegel says.
• Choose medications with simplified dosing schedules (fewer doses per day) when possible.
• Request packaging in easy-open daily dosing bottles.
• Give patients written instructions for reference (in large type).
Current population trends mean that many dentists will be caring for more elderly patients in their practices. The issue of polypharmacy has become a serious issue for dentists in all areas of practice, but especially for dentists with elderly patients. The medicines used for the management of chronic diseases in older patients can make their treatment more complex than they appear at first glance. Every practitioner should become more familiar with polypharmacy and learn the best ways to avoid the risks it presents to both patient health and your practice.
1. Heft MW, Mariotti AJ. Geriatric pharmacology. In Yagiela JA et al, eds. Pharmacology and therapeutics for dentistry, 6th ed. Philadelphia; Mosby/Elsevier, 2011.
2. Dramatic changes in US aging highlighted in new census, NIH report. 2006. National Institute on Aging website. www.nia.nih.gov/newsroom/2006/03/dramatic-changes-us-aging-highlighted-new-census-nih-report. Accessed September 20, 2013.
3. Moore PA, Guggenheimer J. Medication-induced hyposalivation: etiology, diagnosis, and treatment. Compend Contin Educ Dent. 2008;29(1):50-55.
4. Profile of older Americans, 2011. Department of Health and Human Services, Administration on Aging website. www.aoa.gov/Aging_Statistics/Profile/2011/2.aspx. Accessed September 20, 2013.
5. Tackling the burden of chronic disease in the USA. Lancet. 2009:373(9659):185. doi:10.1016/S0140-6736(09)60048-9. www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)60048-9/fulltext. Accessed September 20, 2013.
6. Prescription drug use among midlife and older Americans. American Association of Retired Persons website. www.aarp.org/health/drugs-supplements/info-2005/rx_midlife_plus.html. April 2005. Accessed September 20, 2013.
7. ACSP Fact Sheet. American Society of Consulting Pharmacists website. https://www.ascp.com/articles/about-ascp/ascp-fact-sheet. Accessed September 20, 2013.
8. The Dentists Insurance Company. Treating elderly patients. The new aged. www.thedentists.com/risk_management/articles/treating_elderly_patients_the_new_aged?prolificView=5. Summer 2006. Accessed September 20, 2013.
9. Walton-Shirley M. Drug-drug interactions: what cardiologists should know and why there was standing room only. www.theheart.org/columns/melissa-walton-shirley-blog/drugdrug-interactions-what-cardiologists-should-know-and-why-there-was-standing-room-only.do. September 1, 2013. Accessed September 20, 2013.
10. Hersh EV, Moore PA. Adverse drug reactions in dentistry. Periodontology. 2008;46(1):109-142.
11. Hersh EV, Moore PA. Drug interactions in dentistry: the importance of knowing your CYPs. JADA. 2004;135(3):298-311.
12. Wilczynska-Borawska M, Baginska J, Borawski J. Is xerostomia a risk factor for cardiovascular mortality in maintenance hemodialysis patients? Med Hypotheses. 2012:79(4):544-548.
13. Akintoye SO, Hersh EV. Risks for jaw osteonecrosis drastically increases after 2 years of bisphosphonate therapy. J Evid Based Dent Pract. 2012;12(3 suppl):S251-S253. doi:10.1016/S1532-3382(12)70048-9.
14. Shiel WC Jr. Herbs: toxicities and drug interactions. www.medicinenet.com/script/main/art.asp?articlekey=7506. Accessed September 20, 2013.