Learning Goals
- Recognize the commonly prescribed medications that are typically used beyond dental practice.
- Know both the generic and brand/trade names of these pharmaceuticals.
- Comprehend how these drugs function and their mechanisms of action.
- Be aware of the possible medical and oral side effects, as well as interactions associated with these medications.
Frequently Encountered Diseases and Prescriptions
Medications are often prescribed by dentists to address various oral conditions, as well as infections and disorders affecting the head and neck. In addition to local anesthetics, practitioners routinely prescribe drugs to manage pain and alleviate patient anxiety and other related issues. It is crucial for dentists to understand the indications, mechanisms of action, and potential side effects of these medications. However, patients frequently take multiple prescription drugs that dental professionals may not be as familiar with. Many individuals receive treatments from their primary care doctors, along with different specialists, leading to a range of medications with unique side effects, physiological effects, and possible interactions that could influence dental care.
This course aims to familiarize dental professionals with some of the most common prescriptions encountered in daily dental practice, particularly those that have implications for treatment planning and patient care. The sheer volume of prescription medications available is evident upon reviewing any popular desk reference. While it is impractical for any single course to cover all medications comprehensively, this program is designed to provide practitioners with insights into the drugs they are likely to encounter frequently.
The text below emphasizes commonly prescribed medications that are utilized to treat prevalent medical conditions in the patient demographic. To illustrate the extensive variety of these medications, they are categorized by general drug type:
- Anti-Anxiety Agents
- Beta Blockers
- Calcium Channel Blockers
- Cholesterol Lowering Agents
- Diuretics
- Hormone Replacements (e.g., estrogen, levothyroxine)
- Anti-Depressants
- ACE Inhibitors
- Cardiac Glycosides
- Asthma Bronchodilators
- Anti-Histamines
- Anti-Coagulants
- Alpha Blockers
- Gastric Acid Inhibitors
- Contraceptive Hormones
This list provides a broad overview of commonly prescribed medications that dental professionals may not typically dispense. Familiarity with these medications will enhance practitioners' understanding of their patients’ overall healthcare needs and enable them to engage more effectively with physicians during treatment planning discussions.
Beta Blockers
Drug Names: (generic names typically end with “-olol”)
- Betapace (sotalol)
- Lopressor (metoprolol)
- Inderal (propanolol)
- Toprol-XL (metoprolol)
- Tenormin (atenolol)
Indications:
- Angina pectoris
- Hypertension
- Migraine prevention
Mechanism of Action:
- The action of this class of drugs involves the blockage of beta adrenergic receptors. These medications compete with and inhibit stimulation at these sites.
- Cardiac specificity: Tenormin selectively targets beta-1 receptors, allowing it to act specifically on cardiac tissues.
- Non-selective agents: Drugs like Inderal affect both beta-1 and beta-2 receptors, competing with all available beta adrenergic receptor sites.
Dental Concerns:
- The pulse rate may decrease, necessitating additional supportive care during lengthy or stressful surgical procedures.
- While vasoconstrictors are not contraindicated, their use should be approached with caution.
Calcium Channel Blockers
Drug Names:
- Procardia (Nifedipine)
- Cardizem CD (Diltiazem)
- Norvasc (Amlodipine)
- Calan (Verapamil)
- Cardene (Nicardipine)
- Vascor (Bepridil)
- Adalat (Nifedipine)
Indications:
- Angina pectoris (ischemic heart disease)
- Hypertension
Mechanism of Action:
- These medications inhibit calcium channels, which facilitate neurotransmission to smooth muscle groups, including the arterial walls. This helps reduce arterial contractility and maintain dilated states for improved blood flow.
Dental Considerations:
- If the patient has a history of angina, it is essential to verify that they are appropriately medicated to prevent episodes during treatment. Limit the appointment duration and intensity as necessary, and consider a referral to a specialist.
- For patients with angina, administer local anesthetics containing vasoconstrictors with caution, and inquire about recent angina episodes or prior triggers related to vasoconstrictor use. Nitroglycerin should be easily accessible.
- There is a link between these medications and gingival hyperplasia, particularly with Procardia. Consult the patient's physician and consider switching to a different calcium channel blocker if needed. Patients should also maintain excellent oral hygiene, and in more severe cases, procedures like gingivoplasty or gingivectomy may be required. Discontinuation of the medication usually resolves the hyperplasia.
SSRIs (Selective Serotonin Reuptake Inhibitors)
Drug Names:
- Prozac (Fluoxetine)
- Zoloft (Sertraline)
- Paxil (Paroxetine)
- Alprazolam (Alprazolam)
Indications:
- Obsessive-compulsive disorder
- Moderate to severe depression
- Anxiety/panic disorders
Mechanism of Action:
- SSRIs function by inhibiting the reuptake of serotonin by neurons in the central nervous system, maintaining normal or elevated serotonin levels. Low serotonin levels are often linked to the psychological disorders treated by these drugs.
- These medications have become some of the most commonly prescribed in the U.S., with Prozac being among the top five. Zoloft and Paxil are also widely prescribed, reflecting the growing prevalence of depression and anxiety-related disorders in the patient population.
Dental Considerations:
- There are no restrictions on using vasoconstrictors with SSRIs, unlike tricyclic antidepressants, where their use may be contraindicated.
- Approximately 10% of patients on SSRIs experience xerostomia (dry mouth), which can lead to increased risk of caries. Regular caries checks, fluoride treatments, and the use of fluoride or remineralization toothpaste and rinses may be necessary.
Anticoagulants
Drug Names:
Indications:
- Circulatory venous thrombosis
- Pulmonary embolism
- Prevention of ischemic heart disease
- Prevention of obstructive stroke
Mechanism of Action:
- Coumadin targets vitamin K-dependent clotting factors, reducing their active forms by 30% to 50%, thus preventing the formation of aberrant blood clots and complications from existing clots.
Dental Considerations:
- Risk of prolonged bleeding necessitates careful planning of invasive procedures, including laboratory tests like prothrombin time (PT) and partial thromboplastin time (PTT).
- Monitor for spontaneous gingival bleeding as a sign of overdosage.
- Caution with over-the-counter medications containing salicylates, as they can enhance Coumadin's effects.
ACE Inhibitors
Drug Names:
- Vasotec (enalapril)
- Zestril (lisinopril)
- Capoten (captopril)
- Lotensin (benazepril)
- Altace (ramipril)
Indications:
- Hypertension
- Congestive heart failure (CHF)
- New for Altace: prevention of heart attack, stroke, diabetes
Mechanism of Action:
- ACE inhibitors block the conversion of angiotensin I to angiotensin II, preventing vasoconstriction and lowering blood pressure by reducing peripheral resistance and fluid retention.
Concerns in Dentistry:
- Angioneurotic edema is a serious side effect; notify the physician if swelling occurs.
- Dizziness and hypotension may cause postural instability; monitor patients accordingly.
- Regular blood pressure checks are advisable during dental visits.
Cholesterol Lowering Agents
Drug Names:
- Lipitor (atorvastatin)
- Zocor (simvastatin)
- Pravachol (pravastatin)
- Mevacor (lovastatin)
Indications:
- Hypercholesterolemia (total cholesterol over 200 mg)
Mechanism of Action:
- These drugs inhibit HMG-CoA reductase, the rate-limiting enzyme in cholesterol production, effectively lowering elevated cholesterol levels.
Concerns in Dentistry:
- Rare risk of rhabdomyolysis if erythromycin is prescribed.
- Monitor for liver function impairment due to potential hepatotoxicity.
Alpha Blockers
Drug Names:
Indications:
Mechanism of Action:
- Alpha blockers decrease tension in blood vessel smooth muscles, leading to improved blood flow by lowering peripheral circulatory resistance.
Concerns for Dentistry:
- Monitor patients for hypotension episodes.
- Recording blood pressure during dental visits is recommended to assess treatment efficacy.
Anti-Histamines
Drug Names:
- Claritin (loratadine), Claritin-D (with pseudoephedrine)
Indications:
- Allergic rhinitis (sneezing, itching, runny nose, tearing)
Mechanism of Action:
- Inhibits histamine binding at peripheral H1 sites in the respiratory system, suppressing allergic symptoms.
Concerns for Dentistry:
- May cause drowsiness and xerostomia (dry mouth); monitor for caries.
- Caution with local anesthetics containing vasoconstrictors, as pseudoephedrine may cause tachycardia.
- Warn patients against using Seldane and Hismanal due to cardiac side effects.
Asthma Bronchodilators
Drug Names:
- Albuterol (albuterol sulfate)
Indications:
Mechanism of Action:
- Stimulates Beta2 adrenergic sites, promoting relaxation of bronchial smooth muscle and aiding in respiratory passage dilation.
Concerns for Dentistry:
- Always have an inhaler and emergency oxygen readily available during treatment.
- Be aware that some dental medications may provoke asthmatic attacks.
Cardiac Glycosides
Drug Names:
Indications:
- Congestive Heart Failure (CHF)
- Cardiac arrhythmias
Mechanism of Action:
- Increases calcium/sodium exchange in cardiac muscle, enhancing contraction strength and modulating ventricular contraction through A-V node inhibition.
Concerns for Dentistry:
- Exercise caution when using local anesthetics with vasoconstrictors due to potential arrhythmias.
- Monitor for xerostomia; prescribe fluoride and remineralization aids as necessary.
Anti-Anxiety Agents (Benzodiazepines)
Drug Names:
- Xanax (alprazolam)
- Librium (chlordiazepoxide)
Indications:
Mechanism of Action:
- Binds to CNS sites to produce anti-anxiety effects, though the exact mechanism is unclear.
Concerns for Dentistry:
- Risk of excessive anxiolytic or depressive effects when combined with other CNS depressants.
- Common side effect includes xerostomia.
Diuretics
Drug Names:
Indications:
- Hypertension (high blood pressure)
- Edema / Congestive Heart Failure (CHF)
Mechanism of Action:
- Inhibits sodium and chloride absorption in the kidneys, increasing water excretion.
Concerns for Dentistry:
- Risk of hypotension and difficulty reclining in the dental chair.
- Monitor for xerostomia.
Gastric Acid Inhibitors
Drug Names:
- Prilosec (omeprazole)
- Prevacid (lansoprazole)
- Pepcid (famotidine)
- Zantac (ranitidine)
- Tagamet (cimetidine)
- Nexium
Indications:
- Gastric and duodenal ulcers
- Gastroesophageal reflux disorder
Mechanisms of Action:
- Most (except Prilosec) are H2 receptor antagonists, preventing acid secretion by competing with histamine for H2 receptor sites.
- Prilosec inhibits the H+/K+ ATPase enzyme in gastric parietal cells, blocking acid production.
Concerns in Dentistry:
- Xerostomia; monitor for increased caries rate.
- Used in treating enamel erosion from gastric sources.
Hormone Replacement
Drug Names:
- Premarin (conjugated estrogen)
- Prempro (conjugated estrogen and medroxyprogesterone)
- Synthroid (levothyroxine)
- Levoxyl (levothyroxine)
Indications:
- Menopausal symptoms, osteoporosis (estrogen replacement medications)
- Hypothyroidism (thyroid hormone replacement medications)
Mechanism of Action:
- Hormone replacement therapy elevates levels of naturally occurring hormones to normal levels following a decrease due to aging or pathology.
Concerns for Dentistry:
- Current research is investigating osteoporosis effects on periodontal bone support, with some studies suggesting significant benefits of hormone replacement therapy for dentition retention.
- Estrogen replacement may increase gingival bleeding.
- Hypothyroid patients may experience macroglossia and deposits on the dorsal surface of the tongue.
Contraceptive Hormones
Drug Names:
- Orthonovum (norethindrone with ethinyl estradiol)
- Ovcon (norethindrone with ethinyl estradiol)
Indications:
- Pregnancy prevention
- Regulation of menstrual cycle / treatment of ovarian cysts
Mechanism of Action:
- Suppresses gonadotropins to inhibit ovulation, alters cervical mucus to inhibit sperm entry, and modifies the endometrium to reduce the likelihood of implantation.
Concerns for Dentistry:
- Increased risk of pregnancy may occur with the concurrent administration of oral antibiotics. Advise patients to utilize alternate birth control methods.
Conclusions
Given the vast array of prescription medications in use today, it is crucial for dental professionals to be familiar with the indications and side effects of the most commonly prescribed drugs. Patients benefit from a practitioner who can recognize and consider the effects of all medications they are taking. Collaborative consultations with physicians and specialists enhance patient care and monitoring of their health conditions. To this end, it is necessary for dental professionals to regularly update their knowledge of medical prescriptions.
Quiz For Prescription Medications
