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Transcript
Putting Medicine Where Your Mouth Is Leesa M. Prunty, Pharm.D., BCPS Jeremy J. Prunty, Pharm.D. Assistant Clinical Professor Marshall School of Pharmacy Clinical Pediatric Specialist Assistant Clinical Professor WVU School of Pharmacy Clinical Internal Medicine Specialist Objectives List the most commonly prescribed medications in pediatric patients Discuss how both local and systemic medications can affect the mouth Assess side effects and potential drug interactions involved with medications commonly prescribed by dental professionals Propose a strategy for integrating interdisciplinary interaction into day to day practice Medication Effects on Oral Health Why is this important? Most common chronic disease of childhood: Dental caries Top 5 Pediatrics Prescriptions 2011 1 Amoxicillin 2 Azithromycin 3 Albuterol Sulfate 4 Montelukast 5 Ibuprofen http://www.practicefusion.com/pages/pr/most-commonly-prescribedmedications.html Medications Affecting Oral pH Chewable tablets Sweetened cough drops Sugary liquid medications Oral pH Solutions Switch to oral tablets when children can swallow Brush teeth after taking medication Take medications with meals Medications Affecting Salivary Flow Xerostomia Over 400 medications with these side effects Anticholinergic side effects Sympathomimetics Medications causing Xerostomia Most common cause of xerostomia Anticholinergics most likely to cause dry mouth Medications with sympathomimentic/anticholinergic effects Antihypertensives may cause in a multitude of mechanisms Managing Medication Induced Xerostomia Take medications in the morning Divide doses where applicable Avoid anticholinergics Nonpharmacologic Xerostomia Therapies Bedroom Humidifier Artificial saliva, moisturizers, lubricants Aritificial saliva typically contain: Carboxymethylcellulose Hydroxymethylcelluose Electrolytes Fluride Perservatives and flavoring Products: Mouth Kote Biotene Gel Biotene liquid Moi-Stir Spray Prescriptions: Caphosol Supersaturated calcium phosphate rinse Pharmacologic Xerostomia Therapies Muscarinic antagonists Pilocarpine 5-10mg TID– QID (max 30mg) Duration – 3-5 hours Cevimeline Side effects are dose dependent Sweating, nausea, rhinitis, flushing, urinary frequency Should not be used in: 30mg tid Cardiovascular disease Duration ~5 hours Uncontrolled asthma Narrow-angle glaucoma Acute iritis Pilocarpine eye drops Four drops of 2% solution swish and swollow/spit TID Chochran Review: Nonpharmacologic Interventions 2013 Meta analysis of 36 trials Looked at various Interventions and outcomes Comparison 1: Saliva stimulants versus placebo Comparison 2: Saliva substitutes versus placebo General conclusion: No strong ev idence to support any one interv ention ov er another Insufficient ev idence Insufficient ev idence Comparison 3: Saliva stimulants versus saliva subsitutes No strong ev idence to support difference of product Patient preference – gum ov er spray Chochran Review: Topical Therapies 2011 Meta analysis of 36 trials Looked at various Interventions and outcomes General conclusion: no strong evidence that any topical treatment is effective for relieving the sensation of dry mouth. Oxygenated glycerol triester spray is more effective than water based spray While gum increases saliva production, no evidence more or less effective than saliva substitutes Medications Affecting Oral Mucosa Hypersensitivities Lichenoid lesions Clindamycin Barbiturates Captopril Carbamazepine Furosemide Ibuprofen Phenytoin Treatment of Mucosal Lesions Stop the offending drug Topical corticosteroids Topical anesthetic ointment Medications Affecting Taste hypogeusia (decreased taste) dysgeusia (distortion of the correct taste) parageusia (bad taste) ageusia (no taste) Medications Affecting Taste Tuccori et al. Drug related taste/smell dysfunctions Macrolides Terbinafine Fluoroquinolones Protein Kinase Inhibitors Medications Affecting Taste Metallic Taste Clarithromycin 5-FU Disulfuram reaction Metronidazole Altered sense of taste Acetazolamide Chemotherapy/Radiation Medication Taste Alteration Solutions Remove offending agent if possible Limited data available Hoven et al. Zinc sulfate and amifostine prophlyaxis for chemotherapy patients Limited benefit Najafizade et al. Zinc sulfate prophylaxis for radiotherapy patients Zinc sulfate 50mg TID x 1 month Bitter, salty, sweet, and sour tastes improved Mizoguchi et al. Sertraline for depressed patient with altered taste Dysgeusia resolved after about 1 month of treatment Medications Affecting Tissue Pigmentation Tetracycline Minocycline Doxycycline Medications Affecting Tissue Pigmentation Temporary tooth stains Chlorhexidine Liquid iron solutions Clarithromycin Medications Causing Gingival Hyperplasia Phenytoin Calcium channel blockers 3 to 62% incidence reported Nifedipine 6.3% incidence reported Cyclosporine 25% incidence in certain populations Gingival Enlargement Medications that Anticoagulate Warfarin (Coumadin®) Enoxaparin (Lovenox®) Fondaparinux (Arixtra®) Dabigatran (Pradaxa®) Rivaroxaban (Xarelto®) Apixaban (Eliquis®) Medications that Anticoagulate Aspirin, Clopidogrel, Prasugrel, Ticagrelor NSAIDs Irreversible inhibition of platelets Reversible inhibition of platelets SNRIs/SSRIs Impaired platelet aggregation Herbals Anticoagulate Ginger Ginkgo biloba Garlic Fish oil Drug interactions St. John’s Wort Medications and Mouth Infections Inhalers: for example Fluticasone/salmeterol (Advair®) Fluticasone/vilanterol (Breo Ellipta®) Beclomethasone (Qvar®) Rinse mouth out after inhaler use to prevent thrush Use a spacer Medications prescribed by dental professionals Fluoride Who needs it? 2 years and older: brush twice daily with fluoride toothpaste People with inadequate amounts of fluoride in drinking water Risk factors: Poor dental hygeine High consumption of sugar Orthodontics Dry mouth Fluoride Mouth rinses First line treatment- Available Rx and OTC Not for use in kids under 6 years Sodium fluoride Neutral product Acidic substances can stain Acidulated phosphate fluoride Best for patients with orthodontic dev ices Stannous fluoride Protects against gingiv itis/plaque Can cause some staining Fluoride Gels Useful for patients needing more than a rinse Sodium fluoride and stannous fluoride available Lower concentration products can be applied at home More concentrated products can be applied by a dental professional Children should rinse with water after use Not recommended for kids under 6 years old Fluoride Pastes Also useful for patients needing more than a rinse Sodium fluoride + stannous fluoride available Should be used at bedtime in place of regular toothpaste Children should rinse with water after use Not recommended for kids under 6 years old Fluoride Oral supplements Intended for people who do not drink fluoridated water or water does not have enough flouride supplementation is recommended level is <0.7 ppm http://apps.nccd.cdc.gov/MWF/Index.asp CDC has specific dosing recommendations for fluoride products http://www.cdc.gov/mmwr/preview/mmwrhtml/rr501 4a1.htm#tab1 Infants – liquid formulation Children – chewable tablets Pre-dental work antibiotics for Endocarditis Prophylaxis Underlying principles in Guidelines Infective Endocarditis (IE) is life-threatening disease and prevention is preferable to treatment infection Certain underlying cardiac conditions predispose to IE Bacteremia with organisms known to cause IE occurs commonly with invasive dental, GI or GU tract procedures Antimicrobial prophylaxis was proven to be effective for prevention of experimental IE in animals Endocarditis Prophylaxis No prospective randomized placebo-controlled studies for the efficacy of antibiotic prophylaxis Absolute risk for IE from a dental procedure is extremely difficult to measure Those at risk should receive prophylaxis any time the gingival tissue, periapical region of teeth, or perforation of oral mucosa Caveats for Prophylactic Antibiotics Assess medication allergies Specific drug and reaction Do not give cephalosporins to anaphylaxis to a penicillin/carbapenem Clindamycin also carries C. diff risk Remind girls taking birth control to use a back up method Pain medication changes Hydrocodone/acetaminophen (Lortab ®) 500mg APAP no longer available as of the end of the year Combined products will have no more than 325mg of acetaminophen Response to patients inadvertently consuming greater than recommended amounts of APAP FDA Drug Safety Communication: Prescription Acetaminophen products to be limited to 325mg per dosage unit; boxed warning will highlight potential for severe liver failure. January 13, 2011. www.fda.gov/drugs/drugsafety/ucm239821. The Fractured Health System The “Silo System” Many professions taking care of 1 patient Egos get in the way of patient care Tradition and prior educational methods Lack of communication Piecing it all Together Current Initiatives Educational collaboration Simulations Health Care Reform Medical Home Models Competency domains required for interprofessional collaborative practice Source: Core competencies for interprofessional collaborative practice. Alfano M C J Dent Educ 2012;76:46-50 ©2012 by American Dental Education Association Questions? References Ciancio SG. Medications' impact on oral health. J Am Dent Assoc. 2004 Oct;135(10):1440-8. Dominguez-Bartmess SN, Tandberg D, Cheema AM, Szalay EA. Efficacy of alendronate in the treatment of low bone density in the pediatric and young adult population. J Bone Joint Surg Am. 2012 May 16;94(10):e62. Ciancio SG. Medications' impact on oral health. J Am Dent Assoc. 2004 Oct;135(10):1440-8 Han SY, Youker S. Metallic taste as a side effect of topical fluorouracil use. J Drugs Dermatol. 2011 Oct;10(10):1201-3. Briggs ER. Taste disturbances related to medication use. Consult Pharm. 2009 Jul;24(7):538-43. Hovan AJ, Williams PM, Stevenson-Moore P, Wahlin YB, Ohrn KE, Elting LS, Spijkervet FK, Brennan MT; Dysgeusia Section, Oral Care Study Group, Multinational Association of Supportive Care in Cancer (MASCC)/International Society of Oral Oncology (ISOO). A systematic review of dysgeusia induced by cancer therapies. Support Care Cancer. 2010 Aug;18(8):1081-7. Mizoguchi Y, Monji A, Yamada S. Dysgeusia successfully treated with sertraline. J Neuropsychiatry Clin Neurosci. 2012 Spring;24(2):E42 Najafizade N, Hemati S, Gookizade A, Berjis N, Hashemi M, V ejdani S, Ghannadi A, Shahsanaee A, Arbab N. Preventive effects of zinc sulfate on taste alterations in patients under irradiation for head and neck cancers: A randomized placebocontrolled trial. J Res Med Sci. 2013 Feb;18(2):123-6. References Tuccori M, Lapi F, Testi A, Ruggiero E, Moretti U, V annacci A, Bonaiuti R, Antonioli L, Fornai M, Giustarini G, Scollo C, Corona T, Ferrazin F, Sottosanti L, Blandizzi C. Druginduced taste and smell alterations: a case/non-case evaluation of an italian database of spontaneous adverse drug reaction reporting. Drug Saf. 2011 Oct 1;34(10):849-59. FDA Drug Safety Communication: Prescription Acetaminophen products to be limited to 325mg per dosage unit; boxed warning will highlight potential for severe liver failure. January 13, 2011. www.fda.gov/drugs/drugsafety/ucm239821. Comparison of Fluoride Products. Pharmacist’s Letter Detail-Document # 290910. September 2013. Oral Health: The Pharmacist’s Role. Pharmacist’s Letter. Self-Study Course #130209. V olume 2013, Course No. 209. Available at: http://pharmacistsletter.therapeuticresearch.com/ce Lodi G, Figini L, Sardella A, Carrassi A, Del Fabbro M, Furness S. Antibiotics to prevent complications following tooth extractions. Cochrane Database Syst Rev. 2012 Nov 14;11:CD003811. Furness S, Bryan G, McMillan R, Birchenough S, Worthington HV. Interventions for the management of dry mouth: non-pharmacological interventions. Cochrane Database Syst Rev. 2013 Sep 5;9:CD009603. Furness S, Worthington HV, Bryan G, Birchenough S, McMillan R. Interventions for the management of dry mouth: topical therapies. Cochrane Database Syst Rev. 2011 Dec 7;(12):CD008934. References Treatment of Dry Mouth. Pharmacist’s Letter Detail Document #261006. Vol. 26, October 2010. Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M, Bolger A, Cabell CH, Takahashi M, Baltimore RS, Newburger JW, Strom BL, Tani LY, Gerber M, Bonow RO, Pallasch T, Shulman ST, Rowley AH, Burns JC, Ferrieri P, Gardner T, Goff D, Durack DT; American Heart Association. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. J Am Dent Assoc. 2008 Jan;139 Suppl:3S-24S. Review. Erratum in: J Am Dent Assoc. 2008 Mar;139(3):253. Rozier RG, Adair S, Graham F, Iafolla T, Kingman A, Kohn W, Krol D, Levy S, Pollick H, Whitford G, Strock S, Frantsve-Hawley J, Aravamudhan K, Meyer DM. Evidencebased clinical recommendations on the prescription of dietary fluoride supplements for caries prevention: a report of the American Dental Association Council on Scientific Affairs. J Am Dent Assoc. 2010 Dec;141(12):1480-9.
