1. C123
MANAGING THE GERIATRIC PATIENT
ANN ESHENAUR SPOLARICH, RDH, PHD
THURSDAY, FEBRUARY 21
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3. COURSE TITLE: Pharmacologic Management of the Geriatric Patient: Oral
Health Care Considerations
COURSE INSTRUCTOR: Ann Eshenaur Spolarich, RDH, PhD
COURSE CREDITS: 3 CEUs
COURSE DATE: February 22, 2013
_____________________________________________________________________________
COURSE DESCRIPTION: The purpose of this course is to review characteristics and disease
trends among the aging population, and oral disease risks associated with medications and
common systemic diseases. Most patients take multiple medications, many of which have oral
complications and drug interactions of significance to dentistry. Medication therapies, oral drug
and disease complications, drug interactions and dental practice management considerations will
be discussed. Recommendations for treatment modifications and oral hygiene self-care programs
will 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 course
instructor.
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-headedness
II. MAJOR TRANQUILIZERS/ANTIPSYCHOTICS
A. 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 retention
C. 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 signs
TYPICAL ANTIPSYCHOTICS ATYPICAL ANTIPSYCHOTICS
chlorpromazine (Thorazine) = Schizophrenia, aripiprazole (Abilify) = Commonly used agent in
nausea/vomiting, intractable hiccups, schizophrenia, treatment and stabilization of
combativeness bipolar disorder
-Low risk of EPS
-Does not cause as much weight gain as other
antipsychotics, but may be less effective than
others
fluphenazine (Prolixin) = management of clozapine (Clozaril) = Schizophrenia; severe OCD,
psychotic disorders and schizophrenia; improves childhood psychosis, attempted suicide, substance
outcomes in patients with psychoses who are abuse recovery
nonadherent 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, bipolar
RX for schizophrenia and Tourette’s; severe disorder, acute agitation
behavioral problems in children
-EPS of TMJ
pimozide (Orap) = suppression of severe motor and olanzapine and fluoxetine (Symbyax) = treatment
phonic tics with Tourette’s of depressive episodes associated with bipolar
-prolongs QT interval: consult physician prior to disorder
administering vasoconstrictor
prochlorperazine (Compro, Compazine) = paliperidone (Invega) = Schizophrenia
antiemetic; psychosis, anxiety
-EPS side effect: torticollis (neck muscle spasm)
promethazine (Phenadoz, Phenergan, quetiapine (Seroquel) = Schizophrenia, acute
Promethegan) = antiemetic, antihistamine, manic episodes and/or depressive episodes with
sedative, motion sickness, post-operative pain, bipolar disorder (monotherapy or with lithium)
anesthetic
-EPS side effect: tardive dyskinesia, Parkinson’s
syndrome, akathisia is most common in elderly
patients
thiothixene (Navane) = psychotic disorders in risperdone (Risperdal) = Commonly used agent in
children, rapid tranquilization of agitated child; schizophrenia, acute mania and/or
patients with dementia irritability/aggression with bipolar disorder,
-prolongs QT interval: consult physician prior to behavioral problems with dementia, Tourette’s
administering 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 vasoconstrictor
Why 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 = confusion
Anticholinergic 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 coma
Adverse 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 depression
III. 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; tricyclics
IV. PEPTIC ULCER DISEASE
1. 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 elderly
2. 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 mucosa
3. 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 loss
Oral side effects associated with gastrointestinal medications
V. CARDIOVASCULAR DISEASE
DRUGS THAT ALTER BLEEDING
ANTIPLATELET 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 aspirin
Sudden 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 or
not adhering to aspirin among 50,279 patients at risk for coronary artery disease. Eur Heart J. 2006 Nov;27(22):2667-74. Epub
2006 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 aspirin
Prevention of premature discontinuation of dual antiplatelet therapy
in patients with coronary artery stents: a science advisory from the
American Heart Association, American College of Cardiology, Society
10

13. for Cardiovascular Angiography and Interventions, American College
of Surgeons, and American Dental Association, with representation
from the American College of Physicians.
Grines CL, Bonow RO, Casey DE Jr, Gardner TJ, Lockhart PB, Moliterno DJ, O'Gara P, Whitlow P; American
Heart Association; American College of Cardiology; Society for Cardiovascular Angiography and Interventions;
American College of Surgeons; American Dental Association; American College of Physicians. William Beaumont
Hospital, Royal Oak, Michigan, USA. J Am Dent Assoc. 2007 May;138(5):652-5.
Abstract
BACKGROUND: and Overview. Dual antiplatelet therapy with aspirin and a thienopyridine has been
shown to reduce cardiac events after coronary stenting. However, many patients and health care providers
prematurely discontinue dual antiplatelet therapy, which greatly increases the risk of stent thrombosis,
myocardial infarction and death. CONCLUSIONS AND CLINICAL IMPLICATIONS: This advisory
stresses the importance of 12 months of dual antiplatelet therapy after placement of a drug-eluting stent
and educating patients and health care providers about hazards of premature discontinuation. It also
recommends postponing elective surgery for one year, and if surgery cannot be deferred, considering the
continuation 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/138/5/652
3 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
thrombosis
platelet 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. NSAIDS
Ibuprofen 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 bleeding
FDA Black Box Warning: NSAIDs are associated with an increased risk of adverse
cardiovascular thrombotic events, including fatal MI and stroke.
In 2006, the FDA issued an informational statement to healthcare professionals stating
that “ibuprofen can interfere with the anti-platelet effect of low dose aspirin (81 mg per
day), potentially rendering aspirin less effective when used for cardioprotection and
stroke prevention. Healthcare professionals should advise consumers and patients
regarding the appropriate concomitant use of ibuprofen and aspirin.” 1 The concern is
that 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.” 1
1. U.S. Food and Drug Administration. U. S. Department of Health and Human Services. Information for Healthcare
Professionals: Concomitant Use of Ibuprofen and Aspirin. New Information [9/2006] - Concomitant Use of Ibuprofen and
Aspirin. Available at:
http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm125222.htm
ANTICOAGULANT 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 replacement
ANTITHROMBINS
• 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 effect
Low 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 control
THROMBIN INHIBITORS
dabigatran (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 effects
Indications 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 days
fondaparinux (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 PATIENTS
Disease or Drug Induced Xerostomia
Caries and Demineralization Tooth Sensitivity
Periodontal Disease Fungal Infections
Viral Infections Pain and Ulcerations
Food Packing/Decreased Oral Clearance
Oral signs and symptoms associated with drug-induced xerostomia
Caries Enamel demineralization
Enamel erosion Cemental abrasion on exposed root surfaces
Dentinal hypersensitivity Increased gingivitis and periodontal infection
Opportunistic infections Increased viral infections
Oral ulcerations/stomatitis Taste alteration
Dry, cracked, bleeding lips Fissured, sore tongue
Angular cheilitis Friable oral mucosa
Difficulty speaking, chewing, Difficulty wearing dentures or appliances
swallowing
Drug classes that produce neural effects on the salivary glands
The following are examples of anticholinergic drugs that reduce the volume of serous saliva:
Antidepressants Antiemetics Antihistamines Antihypertensives
Anti-parkinsonian drugs Antipsychotics Antispasmodics
The following are examples of sympathomimetic drugs that produce a viscous, mucinous saliva:
Amphetamines Appetite suppressants
Bronchodilators Decongestants
Sources: 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 Radiol
Endod 97:28-46, 2004; Nähri TO, Meurman JH, Ainamo A: Xerostomia and hyposalivation: causes, consequences and
treatment in the elderly, Drugs & Aging 15:103-116, 1999.
Drug classes associated with causing xerostomia
Antiacne agents Antianxiety agents Anticholinergics/Antispasmodics
Anticonvulsants Antidepressants Antidiarrheals
Antiemetics Antihistamines Antihypertensives
Anti-inflammatory analgesics Antinauseants Anti-parkinsonian agents
16

19. Antipsychotics Anorexiants Bronchodilators
Decongestants Diuretics Muscle Relaxants
Narcotic Analgesics Sedatives
Source: USP DI® Drug Information for the Healthcare Professional, vol 1, ed. 24, Englewood, CO, Micromedix, Inc., 2004.
Taste and Smell Disorders
Drugs that alter taste
Alcohol detoxification agents Alzheimer’s medications
Analgesics (NSAIDS) Anesthetics (general and local)
Anorexiants Antacids
Antianxiety agents Antiarthritics
Anticholinergics Anticonvulsants
Antidepressants Antidiabetics (oral hypoglycemics)
Antidiarrheals Antiemetics
Antifungals Antigout medications
Antihistamine (H1) antagonists Antihistamine (H2) antagonists
Antihyperlipidemics Antiinfectives
Anti-inflammatory/antiarthritics Antimigraine agents
Antiparkinson agents Antipsychotics
Antithyroid medications Antivirals
Anxiolytics/sedatives Asthma preventives
Bronchodilators Calcium-affecting drugs
Cancer chemotherapeutics Cardiovascular medications
CNS stimulants Decongestants
Diuretics Glucocorticoids
Gallstone solubilization agents Hemorheologics
Immunomodulators Immunosuppressants
Irritable bowel syndrome medications Methylxanthines
Nicotine replacement drugs Ophthalmics
Proton pump inhibitors Retinoids, systemic
Salivary stimulants Skeletal muscle relaxants
Vitamins
Source: Gage TW, Pickett FA: Mosby’s dental drug reference, ed. 7, St. Louis, 2005, Elsevier Mosby.
17

20. Systemic drugs associated with lichenoid drug reactions
Category Agents
Analgesic agents NSAIDs, propoxyphene/acetaminophen, acetaminophen/codeine
Antianxiety drugs benzodiazepines
Antiarrhythmics quinidine
Anticonvulsant drugs Depakote
Antineoplastic drugs levamisole
Cardiovascular agents Beta-adrenergic blockers, angiotensin II antagonist, calcium
channel blockers, cardiac glycoside, methyldopa, thiazide
diuretics, potassium supplements
Gastric acid secretion inhibitors H2-antagonists
Hormone replacement Thyroid hormone, insulin, sulfonylureas, metformin, oral
contraceptives, estrogen, progesterone
Photographic Dyes
Uricosuric agent Allopurinol
18

21. COURSE TITLE: Commonly Prescribed Medications and
Managing the Oral Side Effects of Medication Use
COURSE INSTRUCTOR: Ann Eshenaur Spolarich, RDH, PhD
COURSE CREDITS: 3 Hours
COURSE DATE: February 21, 2013
________________________________________________________________________
COURSE DESCRIPTION:
The purpose of this course is to review the 20 most commonly prescribed medications taken by
clients treated in the oral health care environment. In addition, drug interactions, popular drugs
in the media and new drugs in dentistry will be discussed. A comprehensive review of drugs and
dental 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 acetaminophen
3. levothyroxine sodium 4. lisinopril
5. Lipitor 6. simvastatin
7. Plavix 8. Singulair
9. azithromycin 10. Crestor
11. Nexium 12. levothyroxine sodium
13. metoprolol tartrate 14. hydrocodone and acetaminophen
15. Synthroid 16. Lexapro
17. Proair HFA 18. ibuprofen
19. trazodone HCl 20. amoxicillin
INDICATIONS DRUGS
pain relievers hydrocodone and acetaminophen,
ibuprofen
hypercholesterolemia Lipitor, simvastatin, Crestor
hypertension lisinopril, metoprolol
adverse thromboembolic events Plavix
endocrine disorders levothyroxine, Synthroid
antibiotics amoxicillin, azithromycin
antidepressants Lexapro, trazodone
GERD, reflux or hypersecretory disease Nexium
respiratory disease Singulair, ProAir HFA
PAIN RELIEVERS
BRAND NAME: Co-Gesic, hycet, Lorcet, Lortab, Margesic, Maxidone, Norco, Stagesic, Vicodin, Xodol,
Zamicet, Zydone
GENERIC NAME: HYCD/APAP (hydrocodone with acetaminophen)
THERAPEUTIC CATEGORY: opioid analgesic
USE: post-operative pain control
ORAL 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 the
hydrocodone, and increases the risk for toxicity. Dextroamphetamine enhances the analgesic effect of the
hydrocodone. 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 taken
with alcohol, barbituates or carbamazepine (Tegretol) increases the risk for liver toxicity. Chronic use of
acetaminophen may significantly enhance the anticoagulation effects of warfarin (Coumadin).
2

23. BRAND NAME: Caldolor, Ibu, Motrin
GENERIC NAME: ibuprofen
THERAPEUTIC CATEGORY: NSAID
USE: management of mild to moderate pain; inflammatory diseases and rheumatoid disorders, fever,
dysmenorrhea
ORAL COMPLICATIONS: none
DRUG INTERACTIONS: Ibuprofen and other non-selective NSAIDS can interfere with the antiplatelet
and cardioprotective effects of aspirin: follow appropriate timing of dosing. Avoid use in aspirin-allergic
patients. 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 of
ibuprofen may be increased by ACE inhibitors, angiotensin II receptor blockers, antidepressants
(tricyclic, teriary amine), systemic corticosteroids, glucosamine, herbs that have anticoagulant or
antiplatelet 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 of
ibuprofen may be decreased by bile acid sequestrants, NSAIDS and salicylates. Avoid alcohol.
HYPERCHOLESTEROLEMIA
BRAND NAME: Lipitor
GENERIC NAME: atorvastatin
THERAPEUTIC CATEGORY: HMG-CoA reductase inhibitor
USE: hypercholesterolemia
ORAL COMPLICATIONS: none
DRUG INTERACTIONS: The risk for myopathy/rhabdomyolysis is increased with concurrent use of the
macrolide antibiotics clarithromycin and erythromycin, and the azole antifungal agents fluconazole
(Diflucan), itraconazole (Sporanox) and ketoconazole (Nizoral). Risk for rhabdomyolysis also may be
increased with concurrent use of other lipid lowering agents, cyclosporoine, certain calcium channel
blockers (diltiazem (Cardizem), verapamil (Calan)) and protease inhibitors. Atorvastatin may also
increase the effect of levothyroxine (Synthroid).
BRAND NAME: Zocor
GENERIC NAME: simvastatin
THERAPEUTIC CATEGORY: HMG-CoA reductase inhibitor
USE: hypercholesterolemia
ORAL COMPLICATIONS: taste alteration
DRUG INTERACTIONS: The risk for myopathy/rhabdomyolysis is increased with concurrent use of the
macrolide antibiotics clarithromycin and erythromycin, and the azole antifungal agents fluconazole,
itraconazole and ketoconazole. Risk for rhabdomyolysis also may be increased with concurrent use of
other lipid lowering agents, cyclosporoine, certain calcium channel blockers and protease inhibitors. The
anticoagulant effect of warfarin may be increased by simvastatin.
BRAND NAME: Crestor
GENERIC NAME: rosuvastatin calcium
THERAPEUTIC CATEGORY: HMG-CoA reductase inhibitor
USE: 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 familial
hypercholesterolemia
ORAL 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 contraceptives
ethinyl 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 at
least 2 hours after dosing. Bile acid sequestrants may reduce the absorption of rosuvastatin.
HYPERTENSION
BRAND NAME: Prinivil, Zestril
GENERIC NAME: lisinopril
THERAPEUTIC CATEGORY: ACE inhibitor
USE: hypertension, adjunctive therapy for congestive heart failure, post-MI if hemodynamically stable
ORAL COMPLICATIONS: xerostomia, dry cough, angioedema
DRUG INTERACTIONS: Increased risk for hypotension with alcohol, phenothiazines
(antipsychotics)and probenecid. ACE inhibitors increase serum concentrations of digoxin, lithium and
sulfonylureas (oral hypoglycemics). Increased risk for toxicity with potassium or potassium-sparing
diuretics. Diuretics have additive hypotensive effects when used with ACE inhibitors. Caution when
using 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. Antacids
decrease the bioavailability of ACE inhibitors.
BRAND NAME: Toprol-XL
GENERIC NAME: metoprolol succinate
THERAPEUTIC CATEGORY: cardioselective beta blocker
USE: hypertension, angina, prevention of MI, atrial fibrillation; investigational for ventricular
arrhythmias, migraines, essential tremors, aggressive behavior
ORAL COMPLICATIONS: xerostomia
DRUG 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 patients
taking cardioselective beta blockers (lowest dose, least concentration). NSAIDS (ibuprofen,
indomethacin) used for greater than 3 weeks can decrease the antihypertensive effects of the drug. The
effects of beta blockers are decreased with aluminum salts, calcium salts, barbituates, bile acid
sequestrants (cholesterol-lowering drugs), NSAIDS, penicillins, rifampin and salicylates. Beta blockers
may decrease the effects of sulfonylureas (oral hypoglycemics), and may slow the metabolism of
lidocaine. Increased hypotension and bradycardia may be observed with concurrent use of inhaled
anesthetics and fentanyl derivatives.
ADVERSE THROMBOEMBOLIC EVENTS
BRAND NAME: Plavix
GENERIC NAME: clopidogrel
THERAPEUTIC CATEGORY: antiplatelet agent
USE: reduce risk of atherosclerotic events in patients with history of recent MI, stroke, or established
peripheral arterial disease; acute coronary syndrome (unstable angina)
ORAL COMPLICATIONS: none
DRUG INTERACTIONS: Clopidogrel interfere with the metabolism of many medications, including
oral hypoglycemics, phenytoin and some NSAIDS, increasing risk for toxicity. Concurrent use of
clopidogrel with naproxen increases risk for GI bleeding. Anticoagulant medications taken with
antiplatelet medications increases risk for bleeding. Atorvastatin (Lipitor) and macrolide antibiotics
4

25. (clarithromycin, erythromycin) decrease the effects of clopidogrel. Many herbs interact with Plavix and
increase risk for bleeding: discontinue 14 days prior to surgery.
ENDOCRINE DISORDERS
BRAND NAME: Synthroid
GENERIC NAME: levothyroxine
THERAPEUTIC CATEGORY: hormone
USE: hypothyroidism
ORAL COMPLICATIONS: none
DRUG INTERACTIONS: Levothyroxine increases the effects of oral anticoagulants (Coumadin),
causing an increased risk of bleeding. When taken together, toxicity may occur for both levothyroxine
and tricyclic antidepressants (Elavil). Antacids containing aluminum and magnesium, iron, bile acid
sequestrants (colestipol, cholestyramine), and the ulcer medication sucralfate (Carafate) decrease the
absorption of levothyroxine. Certain seizure medications (phenytoin, phenobarbitol and carbamazepine)
and the TB medication rifampin (Rifadin) decrease levothyroxine levels. Levothyroxine may decrease
the effect of oral sulfonylureas.
ANTIBIOTICS
BRAND NAME: Amoxil, Moxatag
GENERIC NAME: amoxicillin
THERAPEUTIC CATEGORY: antibiotic
USE: infections of ear, skin, respiratory and urinary tracts; premedication
ORAL COMPLICATIONS: oral candidiasis and black hairy tongue
DRUG INTERACTIONS: Concomitant use of amoxicillin and erythromycin or amoxicillin and
tetracycline 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, Zmax
GENERIC NAME: azithromycin
THERAPEUTIC CATEGORY: macrolide antibiotic
USE: orofacial and respiratory tract infections; middle ear infections, pharyngitis, strep throat, tonsillitis,
pneumonia; premedication
ORAL COMPLICATIONS: none
DRUG INTERACTIONS: Antacids containing aluminum or magnesium (Maalox, Mylanta) should not
be taken with azithromycin, as antacids decrease serum levels of the drug. Two hours should lapse prior
to taking azithromycin following the use of an antacid. As with erythromycin, azithromycin interacts
with 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 macrolide
antibiotics with the HMG Co-A reductase inhibitors increases the risk for rhabdomyolysis. Antibiotics
decrease the effectiveness of oral contraceptives.
5

26. ANTIDEPRESSANTS
BRAND NAME: Lexapro
GENERIC NAME: escitalopram
THERAPEUTIC CATEGORY: selective serotonin reuptake inhibitor
USE: major depressive disorder; generalized anxiety disorders (GAD)
ORAL COMPLICATIONS: xerostomia, toothache, vomiting
DRUG 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 for
serotonin syndrome. Use of this drug with aspirin, NSAIDS and other drugs that alter coagulation
increases risk for bleeding. Systemic azole antifungals, ciprofloxacin, clarithromycin, diclofenac,
doxycycline, erythromycin, and other CYP3A4 inhibitors may increase the levels and/or effects of
escitalopram. 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 the
levels/effects of escitalopram, including cabamazepine nafcillin, phenobarbital and phenytoin.
BRAND NAME: Oleptro
GENERIC NAME: trazodone
THERAPEUTIC CATEGORY: serotonin reuptake inhibitor/antagonist
USE: major depressive disorder
ORAL COMPLICATIONS: xerostomia, taste alteration
DRUG 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 decrease
levels/effects of dabigatran. Avoid use of methylene blue (used to treat methemoglobinemia and UTI).
GERD OR HYPERSECRETORY DISEASE
BRAND NAME: Nexium
GENERIC NAME: esomeprazole
THERAPEUTIC CATEGORY: proton pump inhibitor
USE: short-term treatment of erosive esophagitis; symptomatic gastroesophageal reflux disease (GERD)
ORAL COMPLICATIONS: xerostomia
DRUG INTERACTIONS: Esomeprazole may increase the levels of carbamazepine, statin drugs, and
some benzodiazepines (diazepam, midazolam, triazolam). Drugs in this class may decrease the
absorption of antiretroviral medications, iron, and systemic antifungal medications (itraconazole,
ketoconazole). Esomeprazole may decrease the levels of phenytoin. Drug absorption is significantly
decreased (43%-53%) when taken with food; take at least 1 hour before meals.
RESPIRATORY DISEASE
BRAND NAME: Singulair
GENERIC NAME: montelukast
THERAPEUTIC CATEGORY: leukotriene-receptor antagonist
USE: prophylaxis and chronic treatment of asthma; seasonal allergies; perennial allergic rhinitis
ORAL COMPLICATIONS: none
DRUG INTERACTIONS: Phenylketonuric patients should be informed that the chewable tablets contain
phenylalanine. Carbamazepine, phenobarbital, phenytoin, rifampin, and nafcillin may decrease the levels
of montelukast. St. John’s wort may also decrease the levels of montelukast.
6

27. BRAND NAME: ProAir HFA
GENERIC NAME: albuterol
THERAPEUTIC CATEGORY: beta 2-adrenergic agonist
USE: asthma, chronic obstructive pulmonary disorder (COPD)
ORAL COMPLICATIONS: xerostomia, altered taste, vomiting, tooth discoloration
DRUG INTERACTIONS: Increased toxicity (cardiovascular effects) is noted when albuterol is
used with any of the following drugs: MAO inhibitors (Marplan, Nardil, Parnate), tricyclic
antidepressants (Elavil), sympathomimetic agents (amphetamines, dopamine) and inhaled
anesthetics(malignant arrhythmias). The effect of albuterol is decreased when used with
nonselective beta blockers. When used with inhaled ipratropium (Atrovent), an increase in the
duration of bronchodilation may occur.
REFERENCES FOR TOP 20 MEDICATIONS
Top 200 Medications for 2011. Source: IMS Health. Available at:
http://www.pharmacytimes.com/publications/issue/2012/July2012/Top-200-Drugs-of-2011
Physicians’ 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 WARNINGS
varenicline (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#safety
azithromycin, 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 MEDICATIONS
FLUORIDE THERAPY
For 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 fluoride
5% 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 THERAPY
1. 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 potential
2. Biotene product line (GlaxoSmithKline): toothpaste, oral gel, mouthrinse, chewing gum
-contain 3 key salivary enzymes found in natural saliva; sodium fluoride, xylitol
3. 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
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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 hours
5. GC Dry Mouth Gel (GC America)
-alcohol free, sugar free, neutral pH, applied as needed
6. Salese (Nuvora)
-lozenge with water absorbing polymer plus xylitol; raises pH; Dentiva: antimicrobial
7. 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 flavor
8. 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 problems
ANTIMICROBIALS
-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 substantivitiy
Important take home messages with antimicrobials:
- chlorhexidine and CPC are cations: drug reactions with SLS and fluoride = wait 30 minutes
after 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 aphthous
ulcers
ANTIFUNGALS
- 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 interactions
Topical 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-evaluate
Topical 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 rest
Antiviral 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
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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