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June 6, 2001. 2. Pharmacologically-Mediated Salivary Gland Dysfunction. June 6, 2001. 3. Oral Effects of Prescribed Drugs. . . RG Smith
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1. Pharmacologically-Mediated Salivary Dysfunction and the Pharmacologic Management of Salivary Diseases Biology of Salivary Glands
Domenica G. Sweier DDS
June 6, 2001
2. June 6, 2001 2 Pharmacologically-Mediated Salivary Gland Dysfunction
3. June 6, 2001 3 Oral Effects of Prescribed Drugs
4. June 6, 2001 4 Oral Manifestations of Systemic Agents Abnormal hemostasis
Altered host resistance
Angioedema
Coated (black hairy) tongue
Dry socket
Dysgeusia
Erythema multiforme
Gingival enlargement Leukopenia and neutropenia
Lichenoid lesions
Movement disorders
Soft-tissue reactions
Salivary gland enlargement
Sialorrhea
Xerostomia
5. June 6, 2001 5 Abnormal Hemostasis
Interfere with platelet function
Decrease prothrombin synthesis in the liver
Require bleeding profile prior to dental procedures
Oral cavity very vascular, need to be sure bleeding profile is conducive to invasive treatment
Examples include coumadin and aspirin
6. June 6, 2001 6 Altered Host Resistance Results from alteration in normal oral microflora leading to an overgrowth of organisms found as normal oral flora
Eliminate or replace drug, if possible, and administer antifungal agents if candidiasis has developed
Caused by broad-spectrum antibiotics, corticosteroids, cancer chemotherapeutics, among others
7. June 6, 2001 7 Angioedema Drug induced hypersensitivity involving mucosal and submucosal layers of upper GI tract
Mild cases treated with antihistamines
Severe cases may be life threatening when the airway is compromised; emergency treatment to restore airway
Has been reported with use of ACE inhibitors, midazolam, ketoconazole
8. June 6, 2001 8 Coated Tongue The most common is Black Hairy Tongue
Usually black, may be shades of brown
Hypertrophy of filiform papillae
Mechanism unknown
Asymptomatic
No treatment indicated
Examples include clonazepam, ketoprofen, tetracycline
9. June 6, 2001 9 Dry Socket Alveolar Osteitis
Lysis of blood clot prior to it being replaced by granulation tissue
Higher incidence in those who smoke and females using BCPs
Preventative and palliative treatment
Do surgery in days 23-28 of BCP cycle
10. June 6, 2001 10 Dysgeusia Taste alteration, medication or metallic taste, changes and distate for food
Exact mechanism unknown; however, may be interaction of medication with trace metal ions which interact with cell membranes of taste pores
May have other causes, imperative to confirm it is drug induced
No treatment
Examples include iron, metronidazole
11. June 6, 2001 11 Erythema Multiforme May be immunologic reaction mediated by deposition of An-Ab complexes in tissues
Symmetrical mucocutaneous lesions with a predilection for oral mucosa, hands and feet
Tongue and lips most involved
Initial presentation as erythema with vesicles and erosions developing within hours.
Normally self limiting
Oral lesions heal without scars
Examples include clindamycin and pentobarbital
12. June 6, 2001 12 Gingival Enlargement Clinically appears as a diffuse swelling of interdental papillae which coalesces into a nodular topography
Theory of direct affect of drug or metabolite on fibroblast which produces proteins and collagen
Oral hygiene, mouth breathing, and crowded teeth may exacerbate condition
Examples include dilantin, cyclosporin
13. June 6, 2001 13 Leukopenia and Neutropenia Alteration of a persons hematopoietic status
Manifested by increased infections, ulcerations, nonspecific inflammation, bleeding gingiva and increased bleeding after a dental procedure
Replace or remove drug if possible
Examples include chloramphenicol and quinine
14. June 6, 2001 14 Lichenoid Lesions Buccal mucosa and lateral border of tongue most often
Wickhams striae
Pain after ulcerations develop
Differ from Lichen Planus in that the drug induced lesions disappear after the drug is removed
Examples include furosemide and methyldopa
15. June 6, 2001 15 Movement Disorders Neuroleptic drugs affect muscles of facial expression and mastication
Once developed, hard to control and is irreversible
Difficult to eat, communicate, and wear prostheses
Movements include:
Pseudoparkinsonism-rigidity, tremor
Akathisia-restlessness
Tardive dyskinesia-repetitive, involuntary
Examples include thorazine and levodopa
16. June 6, 2001 16 Soft Tissue Reactions Include discoloration, ulcerations, stomatitis, glossitis, and pigmentation
A variety of mechanisms
Examples include
Coumadin-ulcerations
Accutane-glossitis
Meprobamate-stomatitis
Minocycline-discoloration
Mercury-pigmentation
17. June 6, 2001 17 Salivary Gland Involvement Appear as salivary gland swelling and pain, may mimic mumps
Differential diagnosis includes more serious conditions, accurate diagnosis important
Mechanism unknown
Treat by removing or replacing drug, if possible
Examples include methyldopa and lithium
18. June 6, 2001 18 Sialorrhea An increase in salivation
An increase in cholinergic stimulation by direct stimulation of parasympathetic receptors
Example: pilocarpine HCl
An inhibition of cholinesterase
Example: neostigmine
19. June 6, 2001 19 Xerostomia May be a result of another condition, must determine cause
Often reported side effect of many drugs
Increased reported effect with prolonged use of drugs and when multiple drugs are used
Most often in elderly where there is an increase in drug use
20. June 6, 2001 20 Xerostomic Medications Anticholinergics
Antihistamines
Antidepressants, antipsychotics
Sedative and hypnotic agents
Antihypertensives
Antiparkinson agents
Problem:
While xerostomia is often listed as a side effect, few clinical trials and studies have definitively established this relationship and/or investigated the mechanisms
21. June 6, 2001 21 Given the many drugs that can induce salivary gland hypofunction, manifested as xerostomia, and the variety of other causes for this condition, it is imperative that a differential diagnosis be formulated and an accurate cause be determined
22. June 6, 2001 22 Pharmacologic Management of Salivary Diseases
23. June 6, 2001 23 Salivary Gland Diseases Aging
Medications
Obstructions
Neoplasms
Foreign body
Diseases
Local
Systemic
Head and Neck Radiation
Chemotherapy
24. June 6, 2001 24 In General Encourage patient to visit the dentist regularly
Address problems when they first appear
Encourage meticulous oral hygiene
Encourage the patient to stay well nourished and well hydrated
Keep an updated list of all medications the patient is taking (Rx, OTC, regularly or not)
Update the medical history often
Keep in communication with physicians and other health care providers, consult when needed
25. June 6, 2001 25 Oral Hygiene Rinse/wipe oral cavity and associated structures after every meal
Rinse/wipe any removable prosthesis
Denture brush
Remove at night and between meals
Anti-fungal soak Mechanical plaque removal
Soft toothbrushes
Moist gauze
Toothettes good for soft tissue cleansing
Use mild toothpaste and avoid alcohol-containing products
Interdental Aids
Floss
Proxy brush
26. June 6, 2001 26 Treatment Modalities: Outline Medication-induced xerostomia
Pain/Inflammation
Stomatitis
Mucositis
Infection
Bacterial
Fungal
Viral
Hyposalivation
Caries
Special Cases
Head and Neck Radiation
Chemotherapy
27. June 6, 2001 27 Medication-Induced Xerostomia Associated more with certain types of medications
Incidence increases with prolonged use and polypharmacy
Increased incidence among elderly
Use of medications and more of them simultaneously: prescription and OTC
Treatment
Replace medication
Alter dose
Alter administration times
Treat xerostomia and associated symptoms
28. June 6, 2001 28 Pain and Inflammation Rinses
Coating Agents
Analgesics
29. June 6, 2001 29 Pain/Inflammation: Rinses Goals
Cleanse
Moisturize
Lubricate
Preparations
Salt and soda (1/2 tsp each in 8 oz warm water) every 2 hours
Salt or soda (1 tsp one or other in 8 oz warm water) every 2 hours
Hydrogen peroxide diluted 1:1 in water or saline; 1-2 days maximum
Particularly useful to debride ulcerated/crusted area
30. June 6, 2001 30 Pain/Inflammation: Coating Agents Goals
Sustained moisturizing and lubricating
Water soluble lubricating jelly
Diclonine hydrochloride 0.5-1.0%
Carbamide peroxide 10%
Home preps
Milk of magnesia
Kaolin with pectin suspension
Avoid preparations containing glycerin
Hygroscopic
31. June 6, 2001 31 Pain/Inflammation: Analgesics Topical Analgesics
Lidocaine 2% viscous
Benadryl 12.5mg/5ml kaopectate
Capsiacin*
Systemic Analgesics
Ibuprofen
Opioids
Be aware of agents that cause GI distress and alter hemostasis
32. June 6, 2001 32 Infection Antifungals
Nystatin 100,000 units/ml
Clotrimazole troches 10mg
When a removable prosthesis is worn, be sure to treat is as well: diulte bleach solution works well Steroids
Kenalog in Orabase 0.5%
Temovate 0.05%
Antibiotics
Penicillin, clindamycin, amoxicillin, cephalosporins
Culture resistant organisms
Chlorhexidine gluconate 0.12%
33. June 6, 2001 33 Caries
Prevention
Chlorhexidine gluconate 0.12%
Fluorides as rinse or applied via custom trays
Stannous fluoride gel 0.4%
Sodium fluoride gel 1.0%, 1.1%
Act, Fluorigard rinse OTC fluoride
Amputation Caries
Circumferential decay at or below the CEJ compromising the integrity of the tooth
Treatment
Restore with amalgam or fluoride-containing and -leaching glass ionomers and other restoratives
34. June 6, 2001 34 Hyposalivation: Substitutes Large Selection
Mouthwashes, toothpastes, moisturizers, gums
Poor patient acceptance
Feels like someone elses saliva Home Remedy Best Tolerated
Frequents sips of water
Ice Chips
Avoid larger ice cubes since the larger surface may actually stick to the dry mucosa
35. June 6, 2001 35 OTC Saliva Substitutes
36. June 6, 2001 36 Saliva Subs: Constituents Proteins
Lactoferrin
Coating Agents
Carboxymethyl cellulose
Preservatives
Preferably none Enzymes
Lactoperoxidase
Glucose Oxidase
Lysozyme
Flavorings
Mint
Citrus
None
37. June 6, 2001 37 Hyposalivation: Stimulation Gustatory
Sugarless hard candies
Avoid citric candies since they may irritate mucositis and promote acidic destruction of tooth structure
Mechanical
Sugarless chewing gums Pharmacological
Pilocarpine HCl, marketed under the brand name Salagen
5mg tablets, one three to four times daily
Titrate up to two tablets per dose, not to exceed 30mg daily dose
Lowest dose effective and tolerated is recommended
38. June 6, 2001 38 Special Cases Head and Neck Radiation
Chemotherapy
39. June 6, 2001 39 Radiation: Pre-Therapy Referral from Physician for consult
Thorough Medical history including medications
Obtain plan of (surgery) radiation including field(s), amount, duration
Complete dental exam, x-rays, and treatment planning
40. June 6, 2001 40 Radiation: Dental Treatment Complete all invasive treatment 10-14 days prior to radiation
When in doubt; extract
Fabricate fluoride trays, provide Rx
Use cotton-tipped applicators if needed
Instruction on diet, hydration, oral hygiene
Instruct on exercises using tongue blades
Educate on signs/symptoms of disease
41. June 6, 2001 41 Radiation: During Weekly checks
Monitor oral hygiene
Reinforce techniques
Monitor muscle trismus
Monitor salivary flow
Salivary substitutes
Salivary stimulation Address problems at first sign
Mucositis/stomatitis
Candidiases
Cheilosis/cheilitis
Caries
Supportive
Encouragement
42. June 6, 2001 42 Radiation: After Place Patient on 3 month recall or less
Avoid any invasive therapy if at all possible
Tissues will not heal as quickly
Wait at least 6 mos prior to construction removable prosthesis Continue
Fluoride trays
Supportive salivary therapy
Monitor for fungal infections
Monitor for bacterial infections
43. June 6, 2001 43 Chemotherapy: Pre-Therapy Referral from Physician for consult
Thorough Medical history including medications
Obtain plan of therapy, which drugs, amount, duration
Determine timing of myelosuppresion
Complete dental exam, x-rays, and treatment planning
44. June 6, 2001 44 Chemotherapy: Dental Treatment Complete all invasive treatment 10-14 days prior to chemotherapy
Avoid periodontal and endodontic surgery
Any surgery with active soft tissue disease--extract
Fabricate fluoride trays, provide Rx
Instruction on diet, hydration, oral hygiene
Educate on signs/symptoms of disease
45. June 6, 2001 45 Chemotherapy: During Weekly checks
Monitor oral hygiene
Reinforce techniques
Monitor myelosuppresion
Monitor salivary flow
Salivary substitutes
Salivary stimulation
Address problems at first sign
Mucositis/stomatitis
Candidiases
Cheilosis/cheilitis
Caries
Supportive
Encouragement
46. June 6, 2001 46 Chemotherapy: After Allow tissues to heal when chemotherapy completed
This varies with the drug(s) used
May return to pre-chemotherapy recall interval
Treatment plan and provide dental treatment per pre-chemotherapy
47. June 6, 2001 47 Summary Pharmacologically-Mediated Salivary Dysfunction
Many medications affect the oral cavity, salivary function specifically
Xerostomia
Seen mostly in elderly
Pharmacologic Management of Salivary Disease
Much morbidity affecting quality of life seen in salivary dysfunction/disease
Review techniques to manage the morbidity