October 15, 2025 • 16 mins
A comprehensive guide for oral health practitioners and educators regarding prescription medications. The text offers detailed information on various drugs, including their drug class, mechanisms of action, pharmacokinetics, indications and dosages, and a list of side effects/adverse reactions. Critically, the sources also include dental considerations sections, which provide specific guidance for managing dental patients who are taking these medications, often focusing on monitoring vital signs, preventing oral infections, managing dry mouth, and addressing potential drug interactions. This content aids in the dental management of medically compromised patients by offering up-to-date knowledge on a wide spectrum of pharmaceuticals, from antivirals and antibiotics to antineoplastics and central nervous system agents.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:00):
Welcome to the deep dive today. Our mission is well,
pretty clear. We're slicing through a huge amount of pharmacology
info out there and getting straight to the critical stuff
from Mosby's Dental Drug Reference, the thirteenth edition excerpts for
you as an oral health practitioner, think of this as
your shortcut mastering the current drugs and crucially figuring out
(00:23):
how to manage medically compromised patients safely exactly.
Speaker 2 (00:27):
You know, every single patient you see is complex. That
medication list they hand you, it's not just a list,
it's basically a clinical roadmap, right, and this reference, thanks
to the authors Alan Meyers, Miroshah and Ruth Tornwell, it
really captures that essential current guidance. We're focusing on the
systemic conditions those newer drug classes too, like monoclonal and bodies,
(00:49):
other biologically targeted agents, and.
Speaker 1 (00:51):
Those newer ones for diabetes, heart disease, cancer.
Speaker 2 (00:54):
Yes, precisely the twenty first century drugs that you're seeing
more and more.
Speaker 1 (00:57):
Okay, so let's be clear about the scope. We're really
zeroing in on the drugs you typically encounter in like
an outpatient's setting.
Speaker 2 (01:02):
Right, that's the idea so generally we're leaving out vaccines,
most biologicals, and medications that are only used, say introoperatively
in a hospital.
Speaker 1 (01:12):
Got it. And the core principle remains, if your patient
has a prescription, they have an underlying medical condition period
and we absolutely need to understand how that impacts what
we do.
Speaker 2 (01:23):
Chair side couldn't agree more. So, let's not waste any time.
Where should we start, Probably with the highest alert area
for dentists.
Speaker 1 (01:29):
Yeah, let's jump right in there.
Speaker 2 (01:31):
Okay, we really have to begin with the big one,
bisphosphonates and the risk of osteonocrosis of the jaw onj
It's dominated dental discussions for well years now.
Speaker 1 (01:42):
Understandably it's a devastating complication.
Speaker 2 (01:44):
It is, but it's one we can help mitigate.
Speaker 1 (01:46):
Okay, let's quickly unpack the mechanism we're talking about. Drugs
like pomidronate, editronate, the bisphosphonates, they work by inhibiting osteoclasts, right,
slowing down calcium res orgy.
Speaker 2 (01:56):
Exactly the slow bone turnover, which is you know, great
for treating osteoporosis or certain cancers, but it creates a
huge problem when you need bone to heal like after
an extraction.
Speaker 1 (02:06):
Right, the healing process.
Speaker 2 (02:07):
Is key precisely, and the risk is there, whether it's
oral byth phosphonates like a landronaate fosamax is the common one,
or if they're getting venus anti resorptive therapy yea. But
and this is important, the reference gives us a really
critical actionable guideline.
Speaker 1 (02:23):
Okay, what's the guideline.
Speaker 2 (02:24):
Here's the clinical gold standard for you. If your patient
is taking oral byz phosphonates and they've been on them
for less than four years A and D, they have
no other clinical risk factors.
Speaker 1 (02:34):
Like cortico storied use or other systemic issues.
Speaker 2 (02:37):
Exactly. If those conditions are met less than four years,
no other risk factors, then generally you don't need to
alter or delay planned oral surgery.
Speaker 1 (02:46):
Wait, really, less than four years, no other risks precede
as planned. That's huge. That's a massive clarification.
Speaker 2 (02:52):
It is it says unnecessary delays and consults. But this
is the crucial butt.
Speaker 1 (02:57):
What if they're past that four year mark or they
do have those compounding risk factors.
Speaker 2 (03:01):
Then the risk profile changes immediately, it goes way up.
That patient needs a thorough risk assessment. You absolutely need
a consult with their physician, and you might need to
seriously consider alternative treatments to avoid invasive procedures if possible. Okay,
and remember, if they're on venous anti resorptive therapy, it
doesn't matter how long, they're always in the high risk category,
(03:23):
full stop.
Speaker 1 (03:24):
That venous distinction is critical. Yeah, Okay, that guidance alone
is incredibly valuable. Let's pivot now from localized bone risk.
Let's talk systemic issues, specifically managing patients undergoing cancer treatment. Right,
the sources highlight antiineoplastics like iderubicin, desatinob cyclophosphormide, methotrexate. These
are definitely high alert primarily because of milosuppression.
Speaker 2 (03:45):
Correct, Yes, miles suppression is the big one. It impacts
the entire blood system. We're talking leikipenia, so low white cells,
drompocyte apenia, low platelets, anemia, low red cells.
Speaker 1 (03:55):
So clinically, what does that look like acute bloodysgratious.
Speaker 2 (03:58):
That's exactly it. Patient can't fight infection effectively, they can't
clot properly, and their healing is significantly impaired.
Speaker 1 (04:05):
Okay, So say a patient comes in there on is
athioprene or iphosphamide. How do we jerricide detect and manage
potential nutropenia.
Speaker 2 (04:15):
You have to be hypervigilant. Look for signs like unexplained bleeding,
maybe gums that bleed excessively during probing, wounds that just
aren't healing, or sudden oral infections.
Speaker 1 (04:25):
So if you suspect it, If you suspect.
Speaker 2 (04:27):
Nutropenia, blood work is mandatory. You need confirmation, and if
it is confirmed, prophylactic antibiotics are absolutely indicated before any
procedure that breaks the mucosal barrier. That includes deep scaling
and root planning, not.
Speaker 1 (04:40):
Just surgery even deep scaling, got it.
Speaker 2 (04:42):
Absolutely And for some specific agents like everrolamus, there's an
added layer you need to specifically monitor for severe stomatitis, mucositis,
persistent oral ulcerations. These patients often need very specialized gentle
oral care protocols.
Speaker 1 (04:56):
That's a vital connection systemic drug effects showing up as
specific oral symptoms.
Speaker 2 (05:00):
Okay, let's shift gears again. Chronic disease management, cardiovascular agents
and a risk that's maybe less dramatic but still dangerous
orthostatic hypotension. Ah, yes, the head rush when standing up.
It's a real risk for patients on selective beta one
blockers like a tenolol. Alpha adrenergic blockers like doxazosin or
(05:20):
even alphazosin for EPH. They can all cause significant drops
in blood pressure when the patient stands up quickly.
Speaker 1 (05:27):
And the reference gives a clear practical protocol for this,
which is all about patient safety in the operatory.
Speaker 2 (05:32):
Absolutely essential, first monitor vital signs every single appointment, no exceptions.
But the key protocol when you're done with the procedure
is what I call the two minute rule.
Speaker 1 (05:41):
The two minute rule.
Speaker 2 (05:42):
Yeah, after they've been lying supine for a while, have
the patient sit fully upright in the chair for at
least two full minutes before they try to stand. Two
minutes That pause gives their beer receptors time to adjust.
It significantly cuts down the risk of syncope. You know,
fainting could have been to fall right there in your office.
Speaker 1 (06:00):
Simple effective. Okay, beyond just positioning, what about drug interactions?
The classic one anti hypertensives and are standard pain meds
after a procedure. Thinking ACEE inhibitors here like Capta, pril, listen, opril.
Speaker 2 (06:13):
Right, capta pril listen opril. They work by suppressing the
renin angiotensin system lower blood pressure. The big warning here
involves nsaides like ibuprofene exactly, ibuprofen in, domethicine, probably other
standard n size and solicylates too. They can directly decrease
the hypotensive effects of those ACEE inhibitors.
Speaker 1 (06:33):
Wait, hold on, So if I give my patient on
listenopril a standard, say three day course of ibuprofen for
post dot pain, I could actually be messing with their
blood pressure.
Speaker 2 (06:42):
Control potentially, Yes, you could be partially neutralizing the effect
of their ace inhibitor. It's an antagonism.
Speaker 1 (06:49):
Wow. How significant is that?
Speaker 2 (06:51):
It's generally dose dependic cumulative too, But the potential is
definitely real. It doesn't mean you can never use an NSAID,
but it means you absolutely must counsel the patient, tell
them to monitor their blood pressure more closely during that time,
and if you can maybe stick with acetominifin or other
non nsaaight options.
Speaker 1 (07:07):
Okay, that's a crucial interaction to remember. Let's move to
the CNS. Lots of patients on benzodiazepines diazepam, lourazepam, or
anti convulsins like carbamazepine, lamaitrogenie. What's the main clinical takeaway here?
It's less about the gabba mechanism and more about what
not to mix.
Speaker 2 (07:24):
Them with right precisely, forget the deep pharmacology for a second,
focus on the interactions. Benzos give you that axyltic effect,
but it ramps up dangerously when combined with alcohol, opioids,
or and this is a key one often missed, certain
macrolide antibiotics, which ones erythromycin, clariswormycin. They inhibit the metabolism
of many benzodazepines, so the benzo levels in the blood
(07:46):
can spike, leading to really profound dangerous CNUS depression, way
more sedation than expected.
Speaker 1 (07:51):
Okay, good to know about the macrolides. And what about
the long term anti convulsants. The source mentioned a risk
with abrupt withdrawal.
Speaker 2 (07:57):
Yes, very important For a drug like car mezzipine, which
controls seizures, stopping it abruptly can actually trigger status epilepticus
continuous seizures a medical emergency. So if you're ever thinking
about suggesting a drug holiday for any reason that requires
immediate consultation with their prescribing physician. Never advise that on
your own, definitely not okay.
Speaker 1 (08:19):
Finally, in this section pain management for a specific group
patients actively managing opioid dependence using bupernorphine as the example.
Speaker 2 (08:27):
This is a critical dissension both ethically and clinically when
a patient is on bupernorphine or combination products like boonavale
specifically for opioid dependence. The rule is strict avoid prescribing
any drug that has abused potential, full stop.
Speaker 1 (08:41):
So your options for dental pain become.
Speaker 2 (08:43):
Very limited, extremely limited. You must rely on non narcotic
alternatives aspirin, acetaminifin NSAIDs, assuming no other contradications like we
just discussed with ACEE inhibitors, and the reference is explicit
Dounaville is not indicated for managing acute dental pain. You
need a plan probably where out with their addiction specialist
or a prescribing doctor beforehand if possible.
Speaker 1 (09:04):
A very clear boundary there. Okay. Let's shift focus now
to the mouth itself. Starting with probably the most common
drug side effect we see, zerostomia dry mouth.
Speaker 2 (09:14):
Oh absolutely, it's everywhere and in a presence like amatripy line,
and to call energics like glycopyrolate, CNS agents like a mantadine,
even alpha blockers like doxazosin. The list is huge, and.
Speaker 1 (09:25):
It's not just uncomfortable, right, It's a major clinical issue.
Speaker 2 (09:28):
It's a huge risk factor for rampant carries for opportunistic
infections like candydiasis. It's not a minor annoyance for the
dental patient. It's practically a clinical emergency needing management. The
standard advice protocol needs to be drilled at every appointment.
Speaker 1 (09:42):
Okay, what are the non negotiables in that advice?
Speaker 2 (09:44):
All right? Number one sarless gum or candies to stimulate flow.
Number two frequent SIPs of water or using saliva substitutes.
Number three critically tell them to avoid mouth rinses with
high alcohol content. They just make it worse more drying,
counterp ductive totally. And number four ensure they're using daily
home fluoride, prescription strength, toothpaste, fluoride rinses, whatever is appropriate
(10:08):
for their carries risk, which is now elevated. Aggressive anti
carries defense is key, got it?
Speaker 1 (10:13):
Okay, let's touch on anti infectives. We know the basics.
Penicillins ampicillin inhibit bacterial cell walls, Cephalosporines like sephonicides, tazidime.
Due to the absolute baseline is always checking for allergies, right.
Speaker 2 (10:26):
Always, Allergy screening is paramount. But let's look at some
agents used more directly in the mouth. Corhexidine glucnate rents,
for instance. Its mechanism is quite neat.
Speaker 1 (10:35):
How does it work again?
Speaker 2 (10:36):
It's charge based. Corhexinite is positively charged. It reacts with
the negatively charged microbial cell surface, disrupts the membrane, causes
the cytopplisment to basically precipitate out cell death. It sticks
around two, which is why it's effective.
Speaker 1 (10:49):
Interesting, and for fungal issues like thrush or phryngeal Canidia isis,
we often use fluconazole.
Speaker 2 (10:55):
Right gluconsole targets a fungal specific enzyme, a type of
P four fifty that's needed to make orgostral orgostriol is
essential for the fungal cell membrane. No orgostral no viable fungus.
Knowing that helps understand potential resistance mechanisms too.
Speaker 1 (11:10):
Makes sense. Now, before we leave this area, there's a
huge warning a real red flag about a specific topical agent.
Doxycyclin high late gel.
Speaker 2 (11:18):
Yes, this needs to be burned into memory. Doxycyclin in
any systemic form or even this concentrated gel should not
be prescribed before age eight or drum pregnancy.
Speaker 1 (11:27):
Why is that again?
Speaker 2 (11:29):
Because of the risk of permanent tooth discoloration, that classic
gray banding and enamel hypoplasia. It's irreversible. Using it inappropriately
is a massive liability risk.
Speaker 1 (11:38):
Okay, huge caution. There any other considerations with the gel.
Speaker 2 (11:41):
Yes, when you apply it, say for localized periodontal pockets,
you need to instruct the patient very clearly avoid all
oral hygiene procedures brushing, flossing, rinsing in that specific treated
area for a full seven days.
Speaker 1 (11:54):
Seven days.
Speaker 2 (11:55):
Wow, it needs time to stay put in work. Disturbing
it too early negates the benefit.
Speaker 1 (12:00):
Good to know. Okay. Lastly, quick touch on local anesthetics.
Benzocaine the topical.
Speaker 2 (12:05):
Ester main thing with benzocaine. Always screen for hypersensitivity to
ester type anesthetics. It's rareer than our mind allergies, but
it happens, and be aware. Though uncommon, it can cause
allergic ulceration of the mucosa and arcticane. The mind articane
works like other amides, inhibits nerve impulses. Wrap it onset
(12:25):
maybe one to six minutes, lasts about an hour for
polple anesthesia. The interesting clinical bit is its metabolism. It's
primarily broken down by plasma carboxy estrace, not as much
liver involvement as some others, which can be useful in
certain patients.
Speaker 1 (12:40):
Okay, we've covered a massive range here from cancer drugs
to topical gels, which really highlights our next point, the
absolute necessity of the medical consultation.
Speaker 2 (12:49):
It's not optional, it's not just a courtesy. It's essential.
You need that formal console to really assess how well
the patient's underlying disease is controlled, to gauge their ability
both physically and psychologically to handle the stress of the
dental procedure.
Speaker 1 (13:02):
And to request specific tests if needed.
Speaker 2 (13:04):
Exactly, especially if you see signs suggesting blood disgraceias that
unexplained bleeding or infection we talked about, you need to
formally request blood studies. It's simply part of our duty
of care.
Speaker 1 (13:15):
And for practitioners who want to keep learning, stay updated.
Speaker 2 (13:19):
The sources point to the key places, the ADA Center
for Evidence Based Dentistry, the Cochrane Library's Oral Health Group reviews,
and of course the American Heart Association guidelines, particularly for
things like antibiotic profile axis for endocarditis. Those are your
go to reliable resources.
Speaker 1 (13:36):
So let's try to synthesize this for you, the practitioner listening.
What's the big picture. We've navigated some really complex risks,
preventing fainting by just waiting two minutes, avoiding messing up
heart meds with simple pain relievers, Critically understanding and managing
that onj risk. It hammers home that you're not just
treating teeth.
Speaker 2 (13:55):
Are you not at all? You're managing a whole person,
a medically intricate system.
Speaker 1 (14:00):
Seems key, monitoring vitals, checking for dry mouth, constantly making
smart drug choices.
Speaker 2 (14:06):
And tying it all together. Really is understanding pharmacokinetics. You
know how the body handles the drug over time. Its absorption,
it's metabolism, it's half life that's paramount because it defines
the window of risk.
Speaker 1 (14:18):
Can you give an example, sure.
Speaker 2 (14:20):
Think about say de runevir, an anti viral with a
half life around seven hours or lizdexemphetamine, where the active
part dexterum fetamine has a half life of ten to
thirteen hours. Knowing that impacts everything, when should you schedule
their appointment? How long might a potential drug interaction like
that CNS depression we discussed actually last after they leave
(14:41):
your office?
Speaker 1 (14:42):
Ah, so it extends beyond the chair time.
Speaker 2 (14:44):
Absolutely, that knowledge lets you counsel them effectively on managing
potential risks even for the rest of the day.
Speaker 1 (14:50):
That's a powerful point. Okay, that brings us nicely to
our final thought exercise for you, the listener. Here's the scenario.
You have a patient who's been taking oral alendronate this
is phosphonate for six years. They also recently mentioned having
frequent GRD acid reflux, which is a known GI issue.
They need routine scaling and root planning relatively low risk procedure.
(15:12):
What is the primary clinical consideration you must immediately investigate
before you pick up a scaler and what specific advice
about long term oral hygiene is crucial for this particular patient.
Speaker 2 (15:22):
Okay, think about that, the duration, the GRD history, the procedure.
The answer should point you straight towards doing a thorough
ONJ risk assessment immediately. Six years puts them past that
initial four year window, and GRD might be considered a
col morbidity or risk factor needing evaluation. And the hygiene advice,
the key long term advice isn't just brush more, it's
about stressing meticulous, highly effective daily or hygiene specifically to
(15:46):
minimize the need for any future extractions or more invasive procedures,
because those are the procedures that trigger the highest ONJ risk.
Prevention is everything here. That preventive mindset is probably the
ultimate takeaway from this entire deep dive
Welcome to the deep dive today. Our mission is well,
pretty clear. We're slicing through a huge amount of pharmacology
info out there and getting straight to the critical stuff
from Mosby's Dental Drug Reference, the thirteenth edition excerpts for
you as an oral health practitioner, think of this as
your shortcut mastering the current drugs and crucially figuring out
(00:23):
how to manage medically compromised patients safely exactly.
Speaker 2 (00:27):
You know, every single patient you see is complex. That
medication list they hand you, it's not just a list,
it's basically a clinical roadmap, right, and this reference, thanks
to the authors Alan Meyers, Miroshah and Ruth Tornwell, it
really captures that essential current guidance. We're focusing on the
systemic conditions those newer drug classes too, like monoclonal and bodies,
(00:49):
other biologically targeted agents, and.
Speaker 1 (00:51):
Those newer ones for diabetes, heart disease, cancer.
Speaker 2 (00:54):
Yes, precisely the twenty first century drugs that you're seeing
more and more.
Speaker 1 (00:57):
Okay, so let's be clear about the scope. We're really
zeroing in on the drugs you typically encounter in like
an outpatient's setting.
Speaker 2 (01:02):
Right, that's the idea so generally we're leaving out vaccines,
most biologicals, and medications that are only used, say introoperatively
in a hospital.
Speaker 1 (01:12):
Got it. And the core principle remains, if your patient
has a prescription, they have an underlying medical condition period
and we absolutely need to understand how that impacts what
we do.
Speaker 2 (01:23):
Chair side couldn't agree more. So, let's not waste any time.
Where should we start, Probably with the highest alert area
for dentists.
Speaker 1 (01:29):
Yeah, let's jump right in there.
Speaker 2 (01:31):
Okay, we really have to begin with the big one,
bisphosphonates and the risk of osteonocrosis of the jaw onj
It's dominated dental discussions for well years now.
Speaker 1 (01:42):
Understandably it's a devastating complication.
Speaker 2 (01:44):
It is, but it's one we can help mitigate.
Speaker 1 (01:46):
Okay, let's quickly unpack the mechanism we're talking about. Drugs
like pomidronate, editronate, the bisphosphonates, they work by inhibiting osteoclasts, right,
slowing down calcium res orgy.
Speaker 2 (01:56):
Exactly the slow bone turnover, which is you know, great
for treating osteoporosis or certain cancers, but it creates a
huge problem when you need bone to heal like after
an extraction.
Speaker 1 (02:06):
Right, the healing process.
Speaker 2 (02:07):
Is key precisely, and the risk is there, whether it's
oral byth phosphonates like a landronaate fosamax is the common one,
or if they're getting venus anti resorptive therapy yea. But
and this is important, the reference gives us a really
critical actionable guideline.
Speaker 1 (02:23):
Okay, what's the guideline.
Speaker 2 (02:24):
Here's the clinical gold standard for you. If your patient
is taking oral byz phosphonates and they've been on them
for less than four years A and D, they have
no other clinical risk factors.
Speaker 1 (02:34):
Like cortico storied use or other systemic issues.
Speaker 2 (02:37):
Exactly. If those conditions are met less than four years,
no other risk factors, then generally you don't need to
alter or delay planned oral surgery.
Speaker 1 (02:46):
Wait, really, less than four years, no other risks precede
as planned. That's huge. That's a massive clarification.
Speaker 2 (02:52):
It is it says unnecessary delays and consults. But this
is the crucial butt.
Speaker 1 (02:57):
What if they're past that four year mark or they
do have those compounding risk factors.
Speaker 2 (03:01):
Then the risk profile changes immediately, it goes way up.
That patient needs a thorough risk assessment. You absolutely need
a consult with their physician, and you might need to
seriously consider alternative treatments to avoid invasive procedures if possible. Okay,
and remember, if they're on venous anti resorptive therapy, it
doesn't matter how long, they're always in the high risk category,
(03:23):
full stop.
Speaker 1 (03:24):
That venous distinction is critical. Yeah, Okay, that guidance alone
is incredibly valuable. Let's pivot now from localized bone risk.
Let's talk systemic issues, specifically managing patients undergoing cancer treatment. Right,
the sources highlight antiineoplastics like iderubicin, desatinob cyclophosphormide, methotrexate. These
are definitely high alert primarily because of milosuppression.
Speaker 2 (03:45):
Correct, Yes, miles suppression is the big one. It impacts
the entire blood system. We're talking leikipenia, so low white cells,
drompocyte apenia, low platelets, anemia, low red cells.
Speaker 1 (03:55):
So clinically, what does that look like acute bloodysgratious.
Speaker 2 (03:58):
That's exactly it. Patient can't fight infection effectively, they can't
clot properly, and their healing is significantly impaired.
Speaker 1 (04:05):
Okay, So say a patient comes in there on is
athioprene or iphosphamide. How do we jerricide detect and manage
potential nutropenia.
Speaker 2 (04:15):
You have to be hypervigilant. Look for signs like unexplained bleeding,
maybe gums that bleed excessively during probing, wounds that just
aren't healing, or sudden oral infections.
Speaker 1 (04:25):
So if you suspect it, If you suspect.
Speaker 2 (04:27):
Nutropenia, blood work is mandatory. You need confirmation, and if
it is confirmed, prophylactic antibiotics are absolutely indicated before any
procedure that breaks the mucosal barrier. That includes deep scaling
and root planning, not.
Speaker 1 (04:40):
Just surgery even deep scaling, got it.
Speaker 2 (04:42):
Absolutely And for some specific agents like everrolamus, there's an
added layer you need to specifically monitor for severe stomatitis, mucositis,
persistent oral ulcerations. These patients often need very specialized gentle
oral care protocols.
Speaker 1 (04:56):
That's a vital connection systemic drug effects showing up as
specific oral symptoms.
Speaker 2 (05:00):
Okay, let's shift gears again. Chronic disease management, cardiovascular agents
and a risk that's maybe less dramatic but still dangerous
orthostatic hypotension. Ah, yes, the head rush when standing up.
It's a real risk for patients on selective beta one
blockers like a tenolol. Alpha adrenergic blockers like doxazosin or
(05:20):
even alphazosin for EPH. They can all cause significant drops
in blood pressure when the patient stands up quickly.
Speaker 1 (05:27):
And the reference gives a clear practical protocol for this,
which is all about patient safety in the operatory.
Speaker 2 (05:32):
Absolutely essential, first monitor vital signs every single appointment, no exceptions.
But the key protocol when you're done with the procedure
is what I call the two minute rule.
Speaker 1 (05:41):
The two minute rule.
Speaker 2 (05:42):
Yeah, after they've been lying supine for a while, have
the patient sit fully upright in the chair for at
least two full minutes before they try to stand. Two
minutes That pause gives their beer receptors time to adjust.
It significantly cuts down the risk of syncope. You know,
fainting could have been to fall right there in your office.
Speaker 1 (06:00):
Simple effective. Okay, beyond just positioning, what about drug interactions?
The classic one anti hypertensives and are standard pain meds
after a procedure. Thinking ACEE inhibitors here like Capta, pril, listen, opril.
Speaker 2 (06:13):
Right, capta pril listen opril. They work by suppressing the
renin angiotensin system lower blood pressure. The big warning here
involves nsaides like ibuprofene exactly, ibuprofen in, domethicine, probably other
standard n size and solicylates too. They can directly decrease
the hypotensive effects of those ACEE inhibitors.
Speaker 1 (06:33):
Wait, hold on, So if I give my patient on
listenopril a standard, say three day course of ibuprofen for
post dot pain, I could actually be messing with their
blood pressure.
Speaker 2 (06:42):
Control potentially, Yes, you could be partially neutralizing the effect
of their ace inhibitor. It's an antagonism.
Speaker 1 (06:49):
Wow. How significant is that?
Speaker 2 (06:51):
It's generally dose dependic cumulative too, But the potential is
definitely real. It doesn't mean you can never use an NSAID,
but it means you absolutely must counsel the patient, tell
them to monitor their blood pressure more closely during that time,
and if you can maybe stick with acetominifin or other
non nsaaight options.
Speaker 1 (07:07):
Okay, that's a crucial interaction to remember. Let's move to
the CNS. Lots of patients on benzodiazepines diazepam, lourazepam, or
anti convulsins like carbamazepine, lamaitrogenie. What's the main clinical takeaway here?
It's less about the gabba mechanism and more about what
not to mix.
Speaker 2 (07:24):
Them with right precisely, forget the deep pharmacology for a second,
focus on the interactions. Benzos give you that axyltic effect,
but it ramps up dangerously when combined with alcohol, opioids,
or and this is a key one often missed, certain
macrolide antibiotics, which ones erythromycin, clariswormycin. They inhibit the metabolism
of many benzodazepines, so the benzo levels in the blood
(07:46):
can spike, leading to really profound dangerous CNUS depression, way
more sedation than expected.
Speaker 1 (07:51):
Okay, good to know about the macrolides. And what about
the long term anti convulsants. The source mentioned a risk
with abrupt withdrawal.
Speaker 2 (07:57):
Yes, very important For a drug like car mezzipine, which
controls seizures, stopping it abruptly can actually trigger status epilepticus
continuous seizures a medical emergency. So if you're ever thinking
about suggesting a drug holiday for any reason that requires
immediate consultation with their prescribing physician. Never advise that on
your own, definitely not okay.
Speaker 1 (08:19):
Finally, in this section pain management for a specific group
patients actively managing opioid dependence using bupernorphine as the example.
Speaker 2 (08:27):
This is a critical dissension both ethically and clinically when
a patient is on bupernorphine or combination products like boonavale
specifically for opioid dependence. The rule is strict avoid prescribing
any drug that has abused potential, full stop.
Speaker 1 (08:41):
So your options for dental pain become.
Speaker 2 (08:43):
Very limited, extremely limited. You must rely on non narcotic
alternatives aspirin, acetaminifin NSAIDs, assuming no other contradications like we
just discussed with ACEE inhibitors, and the reference is explicit
Dounaville is not indicated for managing acute dental pain. You
need a plan probably where out with their addiction specialist
or a prescribing doctor beforehand if possible.
Speaker 1 (09:04):
A very clear boundary there. Okay. Let's shift focus now
to the mouth itself. Starting with probably the most common
drug side effect we see, zerostomia dry mouth.
Speaker 2 (09:14):
Oh absolutely, it's everywhere and in a presence like amatripy line,
and to call energics like glycopyrolate, CNS agents like a mantadine,
even alpha blockers like doxazosin. The list is huge, and.
Speaker 1 (09:25):
It's not just uncomfortable, right, It's a major clinical issue.
Speaker 2 (09:28):
It's a huge risk factor for rampant carries for opportunistic
infections like candydiasis. It's not a minor annoyance for the
dental patient. It's practically a clinical emergency needing management. The
standard advice protocol needs to be drilled at every appointment.
Speaker 1 (09:42):
Okay, what are the non negotiables in that advice?
Speaker 2 (09:44):
All right? Number one sarless gum or candies to stimulate flow.
Number two frequent SIPs of water or using saliva substitutes.
Number three critically tell them to avoid mouth rinses with
high alcohol content. They just make it worse more drying,
counterp ductive totally. And number four ensure they're using daily
home fluoride, prescription strength, toothpaste, fluoride rinses, whatever is appropriate
(10:08):
for their carries risk, which is now elevated. Aggressive anti
carries defense is key, got it?
Speaker 1 (10:13):
Okay, let's touch on anti infectives. We know the basics.
Penicillins ampicillin inhibit bacterial cell walls, Cephalosporines like sephonicides, tazidime.
Due to the absolute baseline is always checking for allergies, right.
Speaker 2 (10:26):
Always, Allergy screening is paramount. But let's look at some
agents used more directly in the mouth. Corhexidine glucnate rents,
for instance. Its mechanism is quite neat.
Speaker 1 (10:35):
How does it work again?
Speaker 2 (10:36):
It's charge based. Corhexinite is positively charged. It reacts with
the negatively charged microbial cell surface, disrupts the membrane, causes
the cytopplisment to basically precipitate out cell death. It sticks
around two, which is why it's effective.
Speaker 1 (10:49):
Interesting, and for fungal issues like thrush or phryngeal Canidia isis,
we often use fluconazole.
Speaker 2 (10:55):
Right gluconsole targets a fungal specific enzyme, a type of
P four fifty that's needed to make orgostral orgostriol is
essential for the fungal cell membrane. No orgostral no viable fungus.
Knowing that helps understand potential resistance mechanisms too.
Speaker 1 (11:10):
Makes sense. Now, before we leave this area, there's a
huge warning a real red flag about a specific topical agent.
Doxycyclin high late gel.
Speaker 2 (11:18):
Yes, this needs to be burned into memory. Doxycyclin in
any systemic form or even this concentrated gel should not
be prescribed before age eight or drum pregnancy.
Speaker 1 (11:27):
Why is that again?
Speaker 2 (11:29):
Because of the risk of permanent tooth discoloration, that classic
gray banding and enamel hypoplasia. It's irreversible. Using it inappropriately
is a massive liability risk.
Speaker 1 (11:38):
Okay, huge caution. There any other considerations with the gel.
Speaker 2 (11:41):
Yes, when you apply it, say for localized periodontal pockets,
you need to instruct the patient very clearly avoid all
oral hygiene procedures brushing, flossing, rinsing in that specific treated
area for a full seven days.
Speaker 1 (11:54):
Seven days.
Speaker 2 (11:55):
Wow, it needs time to stay put in work. Disturbing
it too early negates the benefit.
Speaker 1 (12:00):
Good to know. Okay. Lastly, quick touch on local anesthetics.
Benzocaine the topical.
Speaker 2 (12:05):
Ester main thing with benzocaine. Always screen for hypersensitivity to
ester type anesthetics. It's rareer than our mind allergies, but
it happens, and be aware. Though uncommon, it can cause
allergic ulceration of the mucosa and arcticane. The mind articane
works like other amides, inhibits nerve impulses. Wrap it onset
(12:25):
maybe one to six minutes, lasts about an hour for
polple anesthesia. The interesting clinical bit is its metabolism. It's
primarily broken down by plasma carboxy estrace, not as much
liver involvement as some others, which can be useful in
certain patients.
Speaker 1 (12:40):
Okay, we've covered a massive range here from cancer drugs
to topical gels, which really highlights our next point, the
absolute necessity of the medical consultation.
Speaker 2 (12:49):
It's not optional, it's not just a courtesy. It's essential.
You need that formal console to really assess how well
the patient's underlying disease is controlled, to gauge their ability
both physically and psychologically to handle the stress of the
dental procedure.
Speaker 1 (13:02):
And to request specific tests if needed.
Speaker 2 (13:04):
Exactly, especially if you see signs suggesting blood disgraceias that
unexplained bleeding or infection we talked about, you need to
formally request blood studies. It's simply part of our duty
of care.
Speaker 1 (13:15):
And for practitioners who want to keep learning, stay updated.
Speaker 2 (13:19):
The sources point to the key places, the ADA Center
for Evidence Based Dentistry, the Cochrane Library's Oral Health Group reviews,
and of course the American Heart Association guidelines, particularly for
things like antibiotic profile axis for endocarditis. Those are your
go to reliable resources.
Speaker 1 (13:36):
So let's try to synthesize this for you, the practitioner listening.
What's the big picture. We've navigated some really complex risks,
preventing fainting by just waiting two minutes, avoiding messing up
heart meds with simple pain relievers, Critically understanding and managing
that onj risk. It hammers home that you're not just
treating teeth.
Speaker 2 (13:55):
Are you not at all? You're managing a whole person,
a medically intricate system.
Speaker 1 (14:00):
Seems key, monitoring vitals, checking for dry mouth, constantly making
smart drug choices.
Speaker 2 (14:06):
And tying it all together. Really is understanding pharmacokinetics. You
know how the body handles the drug over time. Its absorption,
it's metabolism, it's half life that's paramount because it defines
the window of risk.
Speaker 1 (14:18):
Can you give an example, sure.
Speaker 2 (14:20):
Think about say de runevir, an anti viral with a
half life around seven hours or lizdexemphetamine, where the active
part dexterum fetamine has a half life of ten to
thirteen hours. Knowing that impacts everything, when should you schedule
their appointment? How long might a potential drug interaction like
that CNS depression we discussed actually last after they leave
(14:41):
your office?
Speaker 1 (14:42):
Ah, so it extends beyond the chair time.
Speaker 2 (14:44):
Absolutely, that knowledge lets you counsel them effectively on managing
potential risks even for the rest of the day.
Speaker 1 (14:50):
That's a powerful point. Okay, that brings us nicely to
our final thought exercise for you, the listener. Here's the scenario.
You have a patient who's been taking oral alendronate this
is phosphonate for six years. They also recently mentioned having
frequent GRD acid reflux, which is a known GI issue.
They need routine scaling and root planning relatively low risk procedure.
(15:12):
What is the primary clinical consideration you must immediately investigate
before you pick up a scaler and what specific advice
about long term oral hygiene is crucial for this particular patient.
Speaker 2 (15:22):
Okay, think about that, the duration, the GRD history, the procedure.
The answer should point you straight towards doing a thorough
ONJ risk assessment immediately. Six years puts them past that
initial four year window, and GRD might be considered a
col morbidity or risk factor needing evaluation. And the hygiene advice,
the key long term advice isn't just brush more, it's
about stressing meticulous, highly effective daily or hygiene specifically to
(15:46):
minimize the need for any future extractions or more invasive procedures,
because those are the procedures that trigger the highest ONJ risk.
Prevention is everything here. That preventive mindset is probably the
ultimate takeaway from this entire deep dive
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