Presented by Jeff Burgess DDS MSD

Boarded in Oral Medicine

Director – Oral Care Research Associates
To the reader:

All Comments contained herein are

for educational purposes only.
Please consult your attending Dentist
or Physician if you have additional
questions about the information or
management of a problem identified
in this slide show.
 Pharmacology of Drug Metabolism
and Interactions
► Metabolictransformation necessary as lipid
soluble compounds cannot be excreted
 Three basic patterns: inactive drug to active;
active parent to active compound to inactive;
inactive from parent compound
► Oxidativereaction with attachment of a
hydroxyl group – changing ability to attach
to a receptor: hydroxylation
 Pharmacology of Drug Metabolism
and Interactions
► Liver primary site, also kidney and GI epithelium
► After liver metabolization excretion via kidneys,
lung, sweat and saliva, mother’s milk
► Oxidation relies on cytochrome P-450 – through an
energy transfer cascade
► Drug metabolism is directly related to the levels of
this oxidative enzyme
► Five distinct subgroups of P-450
► Drugs inhibit or induce these isoenzymes
 Pharmacology of Drug Metabolism
and Interactions
► High degree of variability between
individuals
► Another key enzyme system: p-glycoprotein
important as it regulates absorption
► Tables are available defining drug
interactions based on the P-450 system
► Smoking increases concentrations of the
isoenzyme CYP1A2 with affect on multiple
drugs including insulin
 Pharmacology of Drug Metabolism
and Interactions
► Computer programs (e.g. ePocretes, PDR on
disk; Micromedex and other internet based
programs) available to help define
interactions
► Multiple texts (e.g. Drug Information
Handbook for Dentistry)
Drugs Used to Manage
Cardiac Disease
 Diuretics
► Potassium sparing agents
 Aldactone, Dyrenium, Midamor
► Potassium depleting agents
 Thiazide type (Chlorothiazide,
Hydrochlorothiazide)
 Loop diuretics (Furosemide)
 Sulfonamide diuretics (Combipres)
 Diuretics

Impact on Dental Care

► Xerostomia
► Oral petechiae/ulceration suggests the
possibility of blood a dyscrasia as a
complication of drug use
► Orthostatic hypotension (uprighting chair)
increases with narcotics, TCAs, barbiturates
► Intravascular injection of anesthetic with
vasoconstrictor + potassium depletion can
cause arrhythmias; also with corticoids
 Diuretics

Impact on Dental Care

► Cardiac stimulants (digoxin, digitalis)
 Erythomycin will enhances absorption
 Epinephrine (intravascular injection) can cause
arrhythmia
 Steroids – can produce digitalis toxicity
 Fluoxetine can cause anxiety, confusion, and
hypertension
 Drugs used for Hypertension
► Angiotensin-Converting Enzyme Inhibitors
 Fosinopril, Lisinopril
► Alpha-Adrenergic Antagonists
 Minipress
► Central-Acting Antihypertensives
 Aldomet, Catapres
► Direct-Acting Vasodilators
 Hydralazine, Minoxidil
 Drugs used for Hypertension
► Beta-Adrenergic Antagonists
 Corgard, Inderal, Lopressor, Tenormin
► Calcium Channel Blockers
 Cardizem, Isoptin, Plendil, Adalat, Procardia
► Nitrates
 Nitrospan, Nitrol, Nitroglyn
 Hypertension

Impact on Dental Care

► ACE: Can cause Angioedema, bone marrow
suppression; NSAIDS < ACE inhibition
► These drugs can increase in orthostatic hypotension
► They are central Acting – producing sedation,
xerostomia, hypotension, painful cervical nodes;
TCAs decrease effect and may increase BP
► Direct Acting: Steroids increase absorption with
minoxidil; arrhythmias; with TCA – hypotension;
NSAIDs decrease effect of hydralazine
 Hypertension

Impact on Dental Care

► Bata Blockers
 High stress can induce angina
 There can be agranulocytosis with increased
susceptibility to infection
 Can produce lightheadedness and hypotension
 Intravascular injection with vasoconstrictor –
can result in severe tachycardia
 Use of Barbiturates can increase sedation
 Hypertension

Impact on Dental Care

► Calcium Channel Blockers
 Produces Gingival Fibrous Hyperplasia
 Produces Dry mouth, sore throat and nasal
stuffiness
 Can produce increased chance of bruising
► Nitrates
 Are an emergency drug in the dental setting
 Drugs used for Cardiac Arrhythmia
► Class 1A Agents
 Procainamide, quinidine, moricizine
► Class 1B Agents
 Mexiletine, tocainide
► Class 1C Agents
 Flecainide, propafenone
► Class III Agents
 Amiodarone
 Arrhythmia

Impact on Dental Care

► These drugs can cause Xerostomia (dry
mouth), dysgeusia (taste change), anxiety
► Procainamide/quinidine – may produce
marrow suppression – with increased
chance of infection, ulcerative stomatitis,
bleeding
► Intravascular epinephrine – arrhythmias
► Co-use of NASIDs increases risk of bleeding
 Agents Used to Treat Cancer,
Lymphoma, Leukemia
► Alkylating Agents
 Cytoxan, Alkeran, busulfan, chlorambucil
► Antimetabolites
 Methotrexate, mercaptopurine, hydroxyurea

Impact on Dental Care

Immunosuppressive effects – with an increased risk of
infection
Hemorrhagic (bleeding) tendency
Typically produce Oral ulceration and mucositis
 Agents Used to Treat Collagen Disease,
Autoimmune, Organ Transplantation

► Cortical Steroids
 Cortisone, dexamethasone, prednisone
► Antimetabolites
 Azathioprine, cyclosporine
 Impact on Dental Care
► Immunosuppressive effects – with an increased
risk of infection
► Can cause more severe or prolonged
periodontal/odontogenic infection, candidiasis
► Chronic use has been associated with cardiac
effects, an effect on stomach mucosa, renal
toxicity (antimetabolites) when coupled with
NSAIDs and antifungals; delayed wound healing,
altered mood, sleep disturbance, edema, facial
swelling, osteoporosis
► Can confound liver disease, colitis, peptic ulcer,
glaucoma
 Drugs Used to Treat Depression
► TCAs
 Amitriptyline, Nortriptyline, doxepin
► SSRIs
 Paxil, Prozac
► Others
 Trazodone
 Impact on Dental Care
► When combined with antihistamines,
barbiturates, benzodiazepines, and
narcotics, there is increased sedation.
► When TCAs are combined with SSRIs or
OTC products like Saint Johns Wart there is
potential for serotonin syndrome.
► Dry mouth, caries
Medications Used to Manage Anxiety
► Benzodiazepines
► Barbiturates

Impact on Dental Care

Are useful for treating the phobic or anxious patient
There is increased sedation
Respiratory depression
There can be an Idiosyncratic effect of barbiturates
(agitation versus sedation)
Addiction potential is high
 Drugs Used to Treat Pain
► Analgesics
 Acetaminophen
 NSAIDs
 Narcotics
► Anticonvulsants
 Neurontin
 Baclofen
 Tegretol
► Antidepressants
► Anti-inflammatory Agents (clobetasol, decadron)
 Impact on Dental Care
► Acetaminophen
 Potential allergy
 May cause liver disease with chronic use
 If there is underlying liver disease – additional
prescription can increase the possibility of
bleeding
 Use care in prescribing in to the patient abusing
alcohol because of possible liver disease
 Impact on Dental Care
► NSAIDs
 Multiple interactions with other drugs
 Caution in prescribing for patients:
►Breast feeding
►With known allergy to ASA
►With peptic ulcer, colitis, asthma, or bleeding
disorder
►With liver disease
►Cardiac implications?
 Impact on Dental Care
► Narcotics
 There can be multiple drug interactions (EtOh, TCA,
Sedatives, MAOs, Warfarin)
 Cause dry mouth
 Chronic use may result in rampant caries
 May produce Nausea
 May have GI effect (constipation)
 Chronic use for Headache can cause Headache persistence
 There is the potential for addiction
 Gender effects (women more susceptible)
 Dosing schedules
 Impact on Dental Care
► Anticonvulsants
 Baclofen
►There is potential for liver toxicity if taken with ibuprofen and other
NSAIDs
►There can be additive effects with CNS depressants or
antihypertensives
►May produce hypoglycemic effects
 Tegretol
►Multiple adverse effects
►Multiple drug interactions
►Hematologic effects
►Cross sensitivity with TCAs
►Can produce sore throat and mouth ulcers
►Dyskinesia
 Impact on Dental Care
► Anticonvulsants
 Neurontin
►Causes dry mouth
►May produce mood changes and mental confusion
►Can cause Sleepiness
►Relatively few interactions with other medications
►Rare - allergy
 Antimicrobials
► Penicillin
 Allergy, tongue discoloration
► Erythromycin
 Nausea, diarrhea, decreased contraceptive effect,
allergy
► Clindamycin
 Allergy, bloating, diarrhea, pseudomembranous colitis
► Tetracycline
 Candidiasis, dental/tongue discoloration, increased and
decreased effects on other antibiobics/medications
 Antimicrobials
► Antifungals
 Associated with Allergy
 Interactions with Etoh, marijuana, cocaine
(decreased effectiveness)
 Caution in pregnant or breast feeding patients
(teratogenic effects)
 Caution in patients with severe liver disease
(additional liver abnormality)
 Antimicrobials
► Antivirals
 Adverse CNS effects in patients using Etoh,
cocaine, marijuana
 Patients taking antibiotics – increased liver
toxicity
 Can cause light headedness
 Allergy
 Summary
►Drugs with direct effects on oral health
►Indirect effects on multiple systems
►Interactions can confound patient care
►Some side effects may be useful (e.g.
sleep, sedation)
Thank You for Viewing This Slide
Show

If you have further questions

about medications and their
effect on Dentistry, please
contact your Dentist or Physician