Chapter 18- Medicines and the dentist.

If you take any prescription drugs [this also includes creams, ointments, regular injections etc] it is very important that you update the dental team at every visit.

If you take lots of drugs and you can’t remember all the names, the spellings, how to pronounce them, the dosage or anything else keep a list or a repeat prescription in your purse or wallet. It’s very important that spellings are correct as often drugs for widely different things have very similar spellings. I’m sure I’m not the only dentist people have said things like ‘Oh you know I take the little pink ones, I don’t know what they’re for the doctor gives ‘em to me’. Could be anything, for anything as far as I’m concerned! Years ago I’ve had to send the patient home without treating them because they didn’t know what tablets they were on, my patients are better trained now.

Co morbidities.

Now a days we are all living longer due to better nutrition, sanitation, clean water supplies, vaccinations,  better diagnosis, medical advances in understanding and treatment, less infant mortality etc . Lots of us are living with what are known as co morbidities that is medical conditions that we live with and have to manage on a day to day basis. 50 years ago we wouldn’t have been living with them as we wouldn’t have been alive. So lots of patients are on drugs and combinations of drugs for these conditions. I think I read somewhere that the average 55 year old is on 5 different tablets. That may not be you but if it’s not you then it means that some people are on a lot more than 5. Lots of drugs a person may be on affect your teeth, your gums, your mouth or your treatment in some way.

It is very important that if you are on any prescription drugs for anything, if you are to visit the dentist that you take your normal dose, at the normal time and you eat your normal meals when you normally would UNLESS TOLD OTHERWISE BY YOUR DENTIST. I have lost count of the number of times someone has fainted on me or felt funny after an injection because their Mum, their Auntie or the cat has told them not to eat before a dental visit!

Side effects and secondary effects.

With drugs there is what is known as the main therapeutic effect, this is its main function but there are 2 other effects;- side effects, which are a nuisance and unwanted and secondary effects which are not the main therapeutic effect but another effect that can be useful in some way. The best example I can think of is Aspirin which is of course a painkiller [analgesic] but also has another effect in stopping the platelets in your blood from clumping together so your blood can form a clot should you cut yourself [ clotting is a complicated many component mechanism more than just this]. So if you were going to have a tooth out it would be a good idea if you clotted afterwards, it is imperative that you tell the dentist in advance.

Allergic reactions and Anaphylactic shock.

A current concern in medicine [of which dentistry is a part] is an increasing incidence of hypersensitivity [allergic type] reactions in people to drugs and other substances.

This can range from itchy skin [this is called a delayed Type 1V reaction] through to full blown anaphylaxis [immediate type 1 reaction] leading to sudden death if not treated promptly.

If you are allergic to anything at all you must tell the dentist.

If you carry an Epipen always have it to hand.

The commonest things I find people are allergic to that affect their treatment and visits to the dentist are;- Penicillin, Erythromycin, latex, oranges, volatile substances, aspirin, chlorhexidine [corsodyl].

Anaphylaxis is most likely to occur at the dentist if the substance is applied or accidentally gets into broken skin or the eyes.

Corsodyl is a mouth wash and gel used extensively in dentistry to treat gum disease. It contains Chlorhexidine. It is only to be used topically.

There have been 2 [that I know of] fatalities in the UK to chlorhexidine in the past 10 years, in both cases this was when chlorhexidine was used to clean a tooth socket after an extraction. The only thing that should be used to clean a socket is salt water [saline].

Dry mouth.

A lot of drugs patients might be on cause a dry mouth. The commonest ones are the ‘anti’s’ antihistamines, antihypertensives and antidepressants but there are lots more.

Patients who have a dry mouth due to reduced salivary flow will be more suseptable to caries [tooth decay] and gum disease as their mouth is not constantly bathed in lovely protective saliva [see chapter 11].

Sleep apnoea is a complex condition of which there are several different types. Obstructive sleep apnoea is where essentially the person stops breathing momentarily while they are asleep, this wakes them up and can occur many, many times during the night. Consequently these poor people have no sleep, are constantly tired and are unsafe to drive or operate machinery. It has many causes and it is very important that these people are seen by a medical specialist in sleep medicine. The treatment for this distressing condition may involve wearing different types of face masks, breathing apparatus or oral [mouth] appliances, further leading to the patient complaining of a dry mouth.

Gum swelling.

Some prescription drugs may cause the patient’s gums to swell. If your gums are swollen, more  debris and bacteria are likely to accumulate ‘down the back’.

Some common ones are;-

  • Phenytoin- taken by people who have epilepsy and other seizure conditions.
  • Calcium channel blockers- taken for hypertension [high blood pressure] and angina. eg Nifedapine.
  • Ciclosporin- taken for rheumatoid arthritis and various other auto immune and inflammatory conditions.

Anaesthetics.

Some drugs a patient may be on might react with certain types of local anaesthetic [injection] and some local anaesthetics should not be used on people with certain medical conditions and pregnancy. Your dental professional is trained to know which these are and to choose a suitable local anaesthetic accordingly. All dental professionals who treat the patient [with the exception of clinical dental technicians] study pharmacology [the science of drugs] in their training and all are required to keep their knowledge up to date by undergoing mandatory continuing professional development [CPD]. New and better drugs and drug regimens are constantly evolving. If the dentist is unfamiliar, doesn’t recognise, or is prescribing something they don’t often use they may look it up to check it out first. In the UK they will use the BNF [British National Formulary] which used to be produced in book form but now is online. This is not because they are useless but because they are being safe and cautious on your behalf. ‘Always look it up’ is a mantra advised in dentistry by specialists in such subjects. Better to waste 2 minutes to refresh ones memory and be sure of your course of action.

Anticlotters.

If you have had a clot [thrombus] while flying for example, a TIA [transient ischaemic attack /mini stroke], a stroke, a heart attack, heart or blood vessel surgery and a hundred and one other reasons, you may be put on anti clotters. This can range from a baby aspirin [75mgs] to other more powerful drugs depending on the severity of your condition. If you self medicate aspirin on a regular basis you must tell the dentist.

If you are on Warfarin you will know that you have to have your blood tested on a regular basis to find your INR [international normalised ratio if you want to know] to make sure you would still clot in a reasonable time. The less often you need to have it tested the more stable your condition. You are given a read out in a ‘yellow book’ in the old fashioned method or probably nowadays a computerised print out. It is very important that you take this information with you to the dentist and that if you are to have anything complicated done that the reading is less than 72hours old.

There are lots of new anti clotters available now which don’t require constant blood tests.

Anyone on anti clotters obviously needs to be managed very carefully at the dentist. Let’s say you need several teeth out for whatever reason, they might have to be done one at a time or I might take out the easiest one first or perhaps clean the patients teeth to assess how much they bleed and if that’s OK carry on.

Whatever you take, make sure you tell the dentist what it is, what it’s for and the dosage [how much, how often and for how long you are to take it] and that whatever you are to have done you make sure you follow to the letter any instructions given to you re after care.

Bisphosphanates.

These are a class of drug that is used in the treatment of osteoporosis and in the treatment of some types of cancers to stop them invading the bone. Here is a simple little explanation;-  so you know you make new cells all the time;- skin cells, blood cells anything else you can think of, you also make new bone cells and to do that you need to get rid of the old ones or your skeleton would just get heavier and heavier. You have special little cells called osteoclasts which nibble away old bone cells so other cells called osteoblasts can make new ones. Bisphosphonates stop the nibbling ones so then the making ones can’t make new bone cells [it is very definitely far more complicated biologically and pharmacologically than this but this will do for now]. If your clinician is to put you on these drugs it is very important that you visit your dentist well in advance [and you should be advised to do so by your GP or medical specialist ] and that your oral hygiene is tip top to ensure as far as possible that you do not have gum disease and you will not need anything extracting whilst you are on these particular type of drugs. The stronger the drug and the bigger the dose, the more likely you are to have complications that affect healing in the mouth. It is absolutely no good turning up at the dentist on the day before you are to have your first dose, it gives the dentist no time to sort anything out that might need sorting.

There is a newer type of drug that is sometimes prescribed for the same reasons, they work in a different way [pharmacologically]. The same precautions are needed. I don’t know if there are more than one of these drugs but you will know what they are for as all the names end in –mab.

Make sure you tell the dentist what drug you are going to be taking, what it’s for, the dosage;- how much, how often and for how long you are to take it and in the case of these drugs how it is to be administered [tablets or injection]. Whatever you are to have done at the dentist make sure you follow to the letter any instructions given re after care.

Pregnancy.

All drugs unless essential should be avoided in pregnant women and some in breast feeding mothers. This also includes some over the counter medicines for example Ibuprofen [Nurofen].

It is very important you read the back of the packet before taking anything if you are pregnant or breast feeding, if in doubt seek medical advice.

Some local anaesthetics [injections], dental materials [eg amalgam], certain treatments [eg bleaching/whitening] should be avoided in pregnancy.

It is very important that you tell your dental professional if you think there might be a possibility you may be pregnant so that your treatment can be managed accordingly for example a temporary restoration to relieve pain and a more permanent solution in the future.

Alternative/ Herbal/ Complimentary etc Medicines/ Suppliments are all dealt with in the next chapter.

Conclusion.

The subjects I have talked about are by no means all of the story, they are the things that most of us in the dental profession manage on a regular day to day basis, hopefully you will understand that you need to;-

  • Tell your dental professional what drugs you are on, what they are for, the correct spellings, the dose, how often you need to take them, for how long and IF THERE ARE ANY CHANGES TO THIS.
  • You always carry a list around with you.
  • You take your normal dose of medication at the normal time, in the manner directed by your doctor and you eat your normal meals if you are to visit the dentist. UNLESS TOLD OTHERWISE BY YOUR DENTIST.
  • Always read the back of the packet first before taking or applying anything for the first time even with over the counter drugs. If you are unsure seek medical advice first. Do not exceed the stated dose.
  • Always follow any instructions given by your dentist, doctor or the back of the packet as to how drugs should be taken.
  • After dental treatment always follow to the letter any instructions given as to after care.

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