CE Course 1

Managing Side Effects of Medication

Credit: Continuing Education Hours: 2
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Table of Contents


Abstract

Dental hygienists discover the drugs taken by clients by conducting thorough comprehensive health history and pharmacologic history reviews. Many clients take multiple medications; therefore, dental hygienists must be aware of the issues related to drug use, including indications, interactions, and adverse drug effects. The ability to evaluate these issues is necessary to accurately assess client status and prevent situations that compromise client safety. Oral side effects are adverse effects that interfere with client function, and increase risks for infection, pain and possible tooth loss.

The purpose of this continuing education course is to review adverse drug effects and to discuss appropriate dental hygiene interventions used to manage oral complications associated with commonly prescribed medications.

The purpose of this continuing education course is to review adverse drug effects and to discuss appropriate dental hygiene interventions used to manage oral complications associated with commonly prescribed medications.


Introduction

Advances in the health-care industry drive pharmaceutical companies to develop new medications to maintain and improve the health and quality of our lives. In recent years, the pharmaceutical industry has experienced tremendous growth in the discovery and launching of new products to consumers. This surge of new products has occurred partly because of an increased efficiency in the FDA approval process, and because of increased promotion and sales by drug manufacturers. An interesting trend has emerged alongside this increased productivity: advertising campaigns that directly market drugs to consumers (DTC).

In 1998, OTC advertising increased the overall number of physician visits by two percent, with large increases in visits associated with conditions promoted by current marketing campaigns. For example, visits for smoking cessation increased by 200 percent during marketing for Zyban a; visits for impotence increased by 100 percent because of Viagra 13 b; and visits for hair growth increased by 80 percent due to Propecia® c Similar trends were noted for osteoporosis, high cholesterol, depression and seasonal allergies.1

Debate continues over the perceived value of DTC advertising. Consumers today can access drug information from radio and television, popular magazines and newspapers, and the scientific literature via electronic search engines over the Internet. Undoubtedly, this information age has impacted upon the choices consumers make about health care, and poses new responsibilities for practitioners who must now respond to consumer requests for brand names.

Some practitioners feel that DTC advertising is problematic, especially when consumers cannot understand why their requested medication may not be the "best" for their given situation, when previously, practitioners would simply have made the choice for them. Conversely, others feel that DTC advertising is encouraging people to seek health care more often, and for conditions for which they otherwise would not have sought treatment at all.1

DTC advertising has indirectly impacted dental professionals. Clients treated in dental care settings are taking new medications prescribed by their physicians, as a direct result of aggressive marketing campaigns targeted at physicians to try newer, "improved" or ''better" drugs. For example, Procardia® b, One of the original calcium channel blockers commonly prescribed to manage angina and hypertension, is now often substituted with Norvasc® b, the newest calcium channel blocker on the market, both of which are manufactured by Pfizer. Notification of FDA approval of Periostat® d appeared in every major syndicated newspaper in the United States, directly raising consumer awareness of the first systemic drug marketed specifically to combat periodontal disease. More than ever before, keeping abreast of these new medications and marketing trends challenge dental professionals to obtain the latest pharmacology information.

Dental hygienists are often the first members of the dental team to learn of drugs taken by clients, through conducting comprehensive health history and pharmacologic history reviews.2 Because clients, especially the elderly, often take multiple medications, dental hygienists will encounter many issues related to drug use, including drug indications, adverse drug effects, drug interactions, and client behaviors that affect compliance and treatment outcomes. The ability to evaluate these issues is necessary to accurately assess the client’s status and to prevent potential drug related emergencies that compromise the client's health and safety.2 The purpose of this course is to review adverse drug effects and to discuss appropriate dental hygiene interventions used to manage the oral complications associated with commonly prescribed medications.

Adverse Drug Effects

The selective effects of drugs are known for all over-the-counter (OTC) and prescription medications. Individual variations in body composition, age, metabolism, and systemic conditions may affect drug actions, and these effects are not always known nor predictable.3,4 AII drugs have the potential to cause adverse or harmful effects that can either be related or unrelated to the principal action of the drug..5,6

Harmful effects that are directly related to drug action are predictable, and occur as a consequence of that action. For example, using aspirin causes increased bleeding due to its anticoagulant effect. These predictable effects are reversible when the drug is discontinued. However, reversal can be difficult for drugs associated with addiction, such as narcotics and alcohol, and at times, these effects can be fatal, as with hypoglycemic coma induced by insulin.5,6

Harmful effects that are unrelated to the principal action of the drug are rare. 5,6 Unusual and unpredictable responses to medications, such as anaphylaxis, are referred to as idiosyncratic reactions. However, there are situations when these effects are likely to occur, such as excessive dosing of a medication. For example, using high doses of aspirin can cause tinnitus, an unwanted effect. In this situation, the effect is predictable, because the dose taken has exceeded that which is considered safe. Teratogenic effects are also examples of these predictable, unwanted effects.

Dental hygienists must understand the differences between drug toxicity, drug allergies and drug side effects Drug toxicity is toxin-induced cellular damage and cell death. Usually, the reactive metabolites formed during metabolic breakdown of the drug in either the liver or the kidney are responsible for causing cell damage, as opposed to the actual drug itself: These reactive metabolites cause permanent changes in cell structure and function, resulting in altered cellular metabolism, cellular mutation and cell death. 5,6

Drug hypersensitivity, or an allergic reaction, occurs when either the drug or its metabolites triggers the immune system and is not predictable. Hypersensitivity is produced with repeated exposure to the same drug. Signs of a true allergy include skin rash, itching, hives, respiratory distress and rhinitis. Other hematologic signs of allergy include hemolytic anemia, agranulocytosis and thrombocytopenia.6 An individual may take a drug nine times, and have an allergic reaction the tenth time. Serious, life-threatening reactions are rare, and include anaphylaxis, hemolysis, and bone marrow suppression.5,6 The penicillins are the most common cause of drug-induced anaphylaxis, affecting one in every 50,000 individuals exposed.6

All drugs produce side effects, which occur for one of two reasons.5 First, a drug may produce an exaggerated effect on its target tissue when given at its correct dose. In this situation, the side effect is an extension of the therapeutic effect of the drug. For example, dangerously low blood sugar may result from taking an oral hypoglycemic agent. Second, a drug may produce an effect on nontarget tissues, so that the effects produced differ from those that are desired. For example, taking NSAIDS for pain control may result in Gl ulceration and bleeding. The FDA requires reporting of all known side effects, which can be found in pharmacology reference texts. Common side effects are presented in Figure I.

Adverse drug effects can also be caused by drug interactions. Drug interactions can be avoided by knowing proper drug relationships. These adverse effects range in severity from minor alterations in drug action to severe, life-threatening situations. The dental hygienist must be able to recognize the early warning signs of drug interactions to maintain the health and safety of the client. As with side effects, the FDA requires the reporting of all known drug interactions, which are updated frequently and routinely published in a variety of professional sources. Drug interactions of significance to dentistry are listed in Figure 2.

Side effects can also occur if the client is not managing medications correctly. Managing medications is difficult for both practitioners and clients, as clients are treated by multiple providers in multiple care settings, all of whom may be prescribing for specific client needs. Further, clients may be self-medicating, under/over-medicating, or may fail to comply because they misunderstood instructions, are unable to read labels, or choose to stop taking their medications due to boredom or intolerance of side effects. Helping clients manage their medications is an important role for the dental hygienist.7 Strategies to improve compliance are listed in Figure 3.

Managing the Oral Side Effects of Medication Use

Management of the oral side effects caused by medication use is an ongoing challenge for dental hygienists. Oral side effects cause client discomfort, and may interfere with the client's ability to adequately chew, swallow and digest food. Some oral side effects place the client at risk for oral trauma, while others contribute to infection, pain and possible tooth loss. Dental hygienists need to accurately diagnose these oral conditions in order to recommend appropriate treatment interventions. Timely recognition and professional interventions are necessary to improve client comfort and function. Common oral side effects of medications are summarized in Figure 4.

Over 400 medications cause xerostomia, making it the most commonly reported oral side effect associated with medication use. For example, eight of the top 20 most commonly prescribed medications for 1998 cause xerostomia.8

Saliva serves multiple roles in maintaining a healthy oral environment.9 First, saliva coats the oral mucous membranes, which maintains tissue integrity, and protects the tissues from injury during mastication, speaking, oral hygiene procedures and wearing appliances.Lubrication from salivary mucins also protects the mucas membranes from ulceration, prevents the penetration of carcinogens, toxins and irritants, and encourages soft tissue repair.10,11.
Second, saliva maintains the balance of the oral ecosystem with immunologic, non-immunologic, and antibacterial processes to prevent microbial colonization and reduce bacterial adherence to the teeth and oral tissues. Third, saliva serves as a buffer for regulating oral and plaque ph. Antibacterial and buffering capacities, coupled with the natural mechanical cleansing activity of saliva, protect the teeth from dental caries and periodontal disease. Finally, structural integrity of the teeth is maintained by salivary pellicle formation, regulation of salivary electrolytes and demineralization of early enamel lesions. Alterations in saliva cause an imbalance in the oral environment, resulting in a variety of oral complications.

Dental hygienists are in an excellent position to educate clients about the multiple oral sequelae associated with drug-induced xerostomia. These include an increased risk for dental caries, periodontal disease and tooth loss; oral trauma and pain; alterations in the oral functions of mastication, speech and swallowing; and opportunistic infections. The following section will address the dental hygiene interventions used to manage the oral complications of medication use.

Intervention No. 1

Fluoride Therapy

The reduction in salivary flow rate causes a change in the nature and quality of the residual saliva. Xerostomic clients demonstrate a more viscous and mucinous saliva, which facilitates food and plaque adherence to tooth surfaces, appliances and oral tissues. Large increases are seen in the levels of Streptococcus mutans in saliva and plaque, the major organism associated with dental caries formation. The pH of the oral cavity lowers, becoming more acidic, which in combination with increased plaque adherence to the teeth, places the client at an increased risk for dental caries.12

Carious lesions associated with xerostomia are often found along the gingival margin on exposed buccal and lingual root surfaces, at and underneath crown margins, and in root furcations. Initially, these surfaces may appear as incipient areas of decalcification along the cervical margin; later, areas of decalcification are evident on posterior cusp tips and incisal edges of anterior teeth. Eventually, carious lesions become circumferential, and invade all surfaces of the enamel.13
,14 Increased enamel erosion and abrasion are also evident in xerostomic clients, which facilitates plaque accumulation, dental caries formation, gingival inflammation and recession.9 Root caries are often found in areas that are difficult to access with daily oral hygiene procedures, leading to extensive destruction of the teeth and possible tooth loss. For teeth that serve as anchors for fixed partial dentures, dental caries destruction is of great significance, as restoration of these areas can be costly for the client, and restorative options may be limited.

Clients experiencing drug-induced xerostomia must be placed on a topical supplemental fluoride, used daily in conjunction with an effective oral hygiene regimen. Fluoride ions become incorporated into the enamel or dentin by replacing hydroxyapatite crystals with fluorapatite crystals, which are more resistant to acid erosion. The resultant acid resistance of the tooth structure decreases the rate of demineralization. Fluoride has also been shown to increase both the size and rate of growth of enamel crystals formed during remineralization, and enhances the natural remineralizing actions of saliva.9,15,16,17

There are many OTC and prescription topical fluoride products on the market, which are available as either dentifrices, gels or mouth rinses. When making a recommendation for a supplemental fluoride, the dental hygienist must consider a client's clinical needs, cost, availability and ease of use. The choice of delivery system for home fluorides varies according to clinical need. Clients who continue to demonstrate a high dental caries rate after using a fluoride rinse for one year, those with a high incidence of root caries, and those with a history of head and neck irradiation may receive a greater benefit from using a topical gel delivered in custom fluoride trays.17 There is some concern that low concentration OTC sodium fluoride rinses (18 Likewise, OTC dentrifices contain less than 1,500 ppm fluoride; therefore, Xerostomic clients will receive a greater benefit from using a prescription strength fluoride dentifrice or topically applied fluoride gel. Clients should be closely monitored to determine compliance with and the efficacy of their home fluoride use, with the understanding that periodic modifications may be necessary over time. Continuous evaluation is critical for clients who have exceptionally high dental caries rates, rampant decay and/or systemic conditions which will cause xerostomia throughout their lifetime. Supplemental fluorides are summarized in Table 1 and Table 2.

It is important to note that clients with permanent xerostomia, such as clients with Sjogren's Syndrome or damage from head and neck radiation, will have a lifetime risk of increased dental caries.14,19, 20 These clients should consider using mouth rinses and dentifrices that contain sodium bicarbonate, which may improve the buffering effects of saliva, thus raising the oral pH and altering pathogenic oral flora.21,22 There are numerous sodium bicarbonate products available on the market, and the effects of these agents warrant further study in these populations.

Xerostomia has also been associated with dentinal hypersensitivity of exposed root surfaces in areas of gingival recession.14,23 In clients with gingival recession, fluorides provide the dual benefit of reduced dentinal hypersensitivity and dental caries control. While clients may experience some relief from using supplemental home fluorides, additional relief may be obtained through the use of fluorides specifically intended for desensitization. Clients with hypersensitivity should be placed on an OTC sensitivity protection dentifrice containing sodium fluoride and potassium nitrate, and treated professionally with sodium fluoride varnishes (Duraphat® k) or stannous Duolide desensitizing agents (Dentinbloc®), all of which occlude the dentinal tubules.

Intervention No. 2

Salivary Replacement Therapy/Salivary Stimulation

When clients exhibit chronic and/or severe xerostomia, symptomatic relief of dry mouth and dry throat may be obtained by using salivary replacement therapy. For most clients, the natural alternative to saliva is water due to its low cost, ease of use and availability. Clients should be encouraged to drink frequently to remain hydrated, and to keep water at their bedsides for relief from nocturnal dryness. However, water is not an adequate saliva substitute, as it lacks the protective physical properties of saliva. Artificial salivary substitutes should be considered.

Most artificial salivas are comprised of sodium carboxymethyl-cellulose, to simulate natural viscosity and improve oral retention; flavoring agents, such as sorbitol and xylitol, for improved taste: and parabens, to inhibit bacterial growth.24,25 Some of these agents also contain fluoride and electrolytes for added dental caries protection. Clients who are allergic to para-aminobenzoic acid or its derivatives, such as ester anesthetics, should not use products that contain parabens. For the general population, salivary substitutes are very safe to use, and may be used as often as needed throughout the day. Long-term compliance may be problematic because of the need for frequent dosing, the inconvenience of carrying these products, and cost.

There are many OTC artificial saliva preparations available. Dental hygienists should recommend salivary replacement therapy for clients with drug-induced xerostomia, clients with Sjogren's syndrome, and for those with permanent salivary dysfunction caused by irradiation damage or removal of salivary glands. Salivary replacement therapy is used in conjunction with supplemental home fluoride therapy. OTC artificial salivas are summarized in Table 3.

The FDA has approved pilocarpine (Salagen®) for treatment of xerostomia caused by head and neck irradiation and from Sjogren's syndrome.26,27,28 Pilocarpine is a cholinergic agonist that stimulates muscarinic acetylcholine receptors in the salivary glands to increase serous salivary flow. This effect is dependent upon the presence of intact salivary gland tissue and nerve supply.24 Pilocarpine is dispensed in 5 mg tablets, at 2 tablets 3-4 times/day, with a total daily dose not to exceed 30 mg. Clients may need to take the drug for a minimum of 90 days to see optimum effects. Pilocarpine is contraindicated for clients with a known hypersensitivity to the drug, uncontrolled asthma or narrow-angle glaucoma. Drug interactions associated with pilocarpine include anticholinergic medications (e.g. antiparkinsonion drugs, carbamazepine, digoxin, sedative antihistamines, tricyclic antidepressants), cholinergic medications (e.g. antiglaucoma drugs) and beta-adrenergic blocking drugs.29,30

Mechanical stimuli can be used to increase salivary flow rates for clients who are unable to take pilocarpine. The act of mastication produces a large mechanical stimulus for increased salivary secretions, which may be mimicked by chewing sugarless gum. Sugarless gums contain alcohol sugars: mannitol, sorbitol and xylitol. Gum chewing provides two benefits: stimulation of salivary flow and decreased risk for tooth decay.14 Streptococcus mutans are inhibited by xylitol, and are fermented by Sorbitol and mannitol.31 Studies have shown that chewing sugarless gum after eating significantly increases plaque pH.32,33,34,35

Dental hygienists should ask their clients if they are using hard candies and breath mints to increase their saliva and to reduce oral malodor; as these are common behaviors of clients with xerostomia. These behaviors can be acceptable, as long as clients are using sugarless products. Indeed, sugarless lemon drops are often used in salivary research projects, as the tart flavor and the mechanical stimulation of sucking on the candy increases salivary flow rates. New research suggests that oral hygiene devices, such as sonic toothbrushes, increase salivary flow rates through mechanical stimulation.36

Intervention No. 3

Antimicrobials

Antimicrobial therapy is an important adjunct in managing the oral complications of xerostomia, and is used to reduce plaque formation, and to prevent or reduce the severity of gingivitis. Regular use of antimicrobials promotes a healthy oral ecosystem, and maintains a balance in the oral flora. There are a variety of available OTC and prescription antimicrobials from which to choose.

Saliva itself is antibacterial, by altering bacteria through complex actions of salivary enzymes and proteins. They may either kill bacteria directly, or interfere with cell growth and replication. The salivary enzyme lactoferrin is bacteriostatic, and kills both aerobic and facultative bacteria by binding iron necessary for bacterial growth. Salivary Iysozyme causes bacterial cell Iysis by binding to the cell wall. Another enzyme, lactoperoxidase, converts the hydrogen peroxide produced by bacteria to hypocyanite, a highly reactive oxidizing agent that effects bacterial acid production and growth. Lactoferrin, Iysozyme and lactoperoxidase are all extremely effective against Streptococcus mutans.37,38,39,40 Biotene® oral care products, including Biotene® alcohol free mouth rinse, contain these key enzymes found in natural saliva, and with regular use, simulate salivary antibacterial properties.

Chlorhexidine gluconate (Peridex™, PerioGard ™) is a broad spectrum antibacterial oral rinse that demonstrates both bacteriostatic and bactericidal properties. Chlorhexidine binds to the bacterial cell wall, and at low concentrations, alters cellular osmotic equilibrium which results in leakage (bacteriostasis), and at high concentrations, results in cell death. Chlorhexidine binds to tooth structure, oral mucosa and salivary proteins as well, and exhibits a high degree of substantivity, enabling a slow release of the agent over time. Despite its potential for increasing supragingival calculus formation, altering taste perception and staining, chlorhexidine is an excellent antimicrobial agent for use in xerostomic patients. Chlorhexidine rinses are the only prescription mouthwashes with FDA approval for efficacy in reducing plaque microorganisms and gingivitis.15,41,42,43

Listerine®x antiseptic mouth rinse is the first and only ADA approved OTC product that reduces and prevents plaque and gingivitis when used in conjunction with daily brushing and flossing.44,45 This essential oil mouth rinse kills bacteria and opportunistic microorganisms within 30 seconds.46 Additional mechanisms of action for Listerine® have recently been elucidated. First, Listerine® has been shown to alter cell surface structure, leading to loss of cell wall integrity, cell lysis and death. These alterations also include changes in cell surface functions, most notably, decreased cellular attachment and aggregation.47 Second, Listerine® inhibits the ability of bacteria to coagulate, thus reducing plaque accumulation.48 Third, full strength Listerine® prevents cell growth in early colonizing plaque bacteria, and when diluted (e.g. to sub lethal doses), is still capable of slowing the growth of these same organisms.49In addition, this mouth rinse is free from side effects, does not promote microbial resistance and does not disrupt the balance of the oral ecosystems.

Other agents available as mouth rinses exhibit antibacterial properties, but do not possess good substance. Fluoride, especially stannous fluoride, is thought to be antibacterial in addition to its cardioprotective and desensitizing effects. Oxygenating agents damage bacteria by altering cell membrane permeability. Sanguinarine, an extract derived from the plant root Sanguinaria canadensis, decreases bacterial cell enzyme activity, and is effective against a broad spectrum of bacteria.15 Viadent® k, the original Sanguinarine mouth rinse, has been reformulated, and now contains cetylpyridinium chloride as its active ingredient.

Most mouth rinses contain alcohol, a chemical known to damage bacteria by denaturing the cell wall. However, the alcohol found in mouth rinses most often serves as the carrier for the active ingredient. Caution must be used when recommending products that contain alcohol, as alcohol may further irritate a xerostomic client's dry oral mucosa.15 Alcohol-containing mouth rinses are contraindicated for use in recovering alcoholics and in young children, who may accidentally ingest these products. Children who ingest more than four ounces of alcohol-containing mouth rinses may experience alcohol intoxication.15

Intervention No. 4

Antifungal Therapy

Parotid saliva contains peptides that have demonstrated antifungal properties against Candida albicans.51 Fungal infections occur as a result of alterations in oral flora, use of antibiotics, immunosuppression, and underlying systemic diseases, such as diabetes. These opportunistic infections are often seen in clients undergoing cancer chemotherapy and those with HIV disease. Fungal infections are especially common among clients with chronic xerostomia.

Fungal infections typically present as a white pseudomembrane overlying bright red tissues, although they may also be erythematous or hyperplastic in appearance.23 These patches of candidiasis may be seen on any mucosal surface, although the palatal mucosa and dorsum of the tongue seem to be highly vulnerable.9,14 The tongue is often red, fissured and sore.52 Angular cheilitis is often present as well..23 Clients who have partial facial paralysis from stroke or those with a loss of vertical dimension from missing teeth or poorly fitting dentures, frequently present with angular chelitis caused by fungal organisms in saliva that collects at the corners of the mouth.X

Fungal infections are treated either topically or systemically, depending upon the extent and severity of the infection. Azole antifungals are used to treat chronic, extensive mucocutaneous candidiasis, while polyenes are used to treat local candidiasis.53 Some antifungals are being used in combination with corticosteroids, such as nystatin and triamcinolone (Mycolog II®), to treat both the fungal infection and the inflammation of angular cheilitis. In general, medications must be used for a minimum of 48 hours after the disappearance of clinical signs and symptoms, with a re-evaluation of the condition 14 days after therapy has been completed. The efficacy of topical drugs is dependent upon contact with the lesions, thus the benefit of using troches, creams and lotions. Liquid swish and swallow preparations are available, and are also used to treat infections associated with dental appliances and dentures. Caution is advised when using systemic antifungal therapy, as resistance may develop which could render the drug ineffective in cases of life-threatening candidiasis.53 Topical and systemic antifungal medications are summarized in Table 4 and Table 5 respectively.

There are several important drug interactions associated with antifungal medications. Absorption of itraconazole (Sporanox® z) and ketoconazole (Nizoral® z) may be altered by antacids, anticholinergic, antispasmodics, histamine H2 antagonists (Tagamet® i, Zantac® a), Prilosec® aa and, Carafate® bb for stomach ulcers, all of which result in treatment failures. Altered blood glucose levels may occur when antidiabetic agents are taken with fluconazole (Diflucan® b) or Sporanox®. Antifungal agents increase prothombin time, increasing the anticoagulant effect of warfarin (Coumadin® cc). Concomitant use of antifungals, phenytoin and cyclosporine increases phenytoin and cyclosporine toxicity Sporanox® and Nizoral® increase serum digoxin levels, which may lead to toxicity. Sporanox® has been shown to significantly increase levels of HMG-CoA reductase inhibitors (Lipitor® h, Mevacor® c, Pravachol® dd, Zocor® h); these drugs may need to be temporarily stopped if systemic use of an azole antifungal is indicated. Amphotericin B increases the toxicity of cyclosporine, corticosteroids and aminoglycosides. Finally, clients should be cautioned not to use alcohol when using antifungal medications.29,53

Concurrent use of azole antifungals and alcohol may result in liver damage. Concomitant use of alcohol with ketoconazole may result in flushing, vomiting, increased respiratory rate and tachycardia.53

To prevent recurrence of fungal infections, clients should be advised to replace all oral hygiene aids (toothbrushes, interproximal aids, etc.) at the onset of and following completion of antifungal therapy. To prevent cross-contamination, dentures, oral appliances and mouth guards should be soaked every night (overnight) in a prescription antifungal solution throughout the course oftreatment.

Dental hygienists should also recommend the daily preventive use of chlorhexidine or Listerine® for clients who present with recurring fungal infections and for those at high risk for infection. Prophylactic use of chlorhexidine has been shown to reduce the incidence and severity of fungal infections in clients undergoing cancer chemotherapy and in clients who are immunosuppressed.54,55,56,57,58 Use of Listerine® has been shown to inhibit the growth of fungal organisms that cause denture stomatitis, on both oral tissues and denture surfaces, and to reduce the associated palatal tissue inflammation.59,60

Intervention No. 5

Antiviral Therapy

In addition to its antimicrobial and antifungal effects, saliva demonstrates an antiviral effect. Salivary and mucosal antibodies are protective against multiple viruses. Salivary mucins help to protect oral tissues from herpes simplex virus and human immunodeficiency virus.61,62,63 Thus, viral infections must be considered in the xerostomic client. Common viral infections seen in dentistry include primary herpes simplex, recurrent herpes simplex (herpes labialis), herpes zoster and HIV. Viral infections are generally preceded by the prodromal signs of local tingling, malaise and fever. Onset is generally acute, with a vesicular eruption of the soft tissues. When the vesicles rupture, small ulcerations appear; which if left untreated, may coalesce to form larger lesions. Viral lesions usually last for 10 to 14 days.53

The management of primary viral infections is generally palliative, and includes the use of combination therapy. Combination therapy may include the use of acyclovir, topical anesthetic rinses (e.g. Dyclonine 5 percent with Benadryl® xx 5 percent in saline), fluids, vitamin and mineral supplements, and rest. As with the antifungal agents, use of systemic antiviral agents should be monitored carefully, as there is an increasing concern for developing resistance to antiviral medications. Side effects and risk of toxicity generally limit the use of systemic antiviral medication to immuno-compromised clients.53 Antiviral agents are summarized in Table 6.

Intervention No. 6

Managing Oral Ulcerations (Non-Viral) and Pain

One of the most important functions of saliva is to provide lubrication, which coats the oral soft tissues and teeth. This lubricant effect is essential for the adequate breakdown of foods during mastication and the resultant formation of the bolus, which is passed through the esophagus to the stomach for digestion. Therefore, xerostomic clients may complain of indigestion, which may be caused by inadequate food breakdown in the oral cavity.

Xerostomic clients present with dry, cracked and fissured lips, tongue and mucous membranes. The oral mucosa may be extremely friable, may stick to the mouth mirror or gloved fingers during retraction, and tear and ulcerate easily. Clients may complain of a heightened sensitivity to spicy or highly flavored foods, or complain of altered taste sensation.The difficulties posed by eating without adequate lubrication combined with taste alteration decreases the enjoyment of eating, and may compromise a client's nutritional intake. The dental hygienist must be alert to changes in weight or poor eating behaviors in clients undergoing cancer therapy, who or are immuno compromised, as proper nutrition is essential for a favorable response to medical treatment.

Recurrent apthous stomatitis may be acute, chronic or recurrent. The etiology is still inconclusive, although these lesions are not of viral origin. Lesions appear as round, cratered ulcerations with a regular border and red halo around the margins. A white pseudomembrane covers the center of the lesion. Sizes of lesions vary, and almost all are painful. Research to date has primarily focused on the incidence and severity of the lesions, while treatment interventions have sought to reduce pain, duration and formation of new lesions.64 Duration of aphthous ulcerations varies, although most lesions disappear within 7 to 10 days.

Currently, there is no drug available to prevent oral ulcerations. Several prescription and OTC agents are available to manage the pain associated with the ulcerations, and others that claim to limit the duration and severity of episodes. Recently, the FDA approved amlexanox (Aphthasol® gg) as the first topical prescription agent for the treatment of aphthous ulcers. Amlexanox is a tasteless, odorless mucoadhesive ointment, which when applied to the ulcer four times per day after meals and at bedtime, accelerates healing and reduces the size of the lesions.65 Amlexanox inhibits inflamatory mediators and has antiallergic properties.

Chlorhexidine has been shown to reduce the total number of days with ulcerations; however, no reduction was seen in either the incidence or severity of ulcerations.66,67 Listerine® has been shown to reduce the incidence, duration and severity of pain in subjects with recurrent aphthous ulcers.64 These reductions were seen over the course of six months, in clients using Listerine® for 30 seconds twice per day. Thus, it may be helpful to recommend Listerine® as both a preventive agent and a therapeutic intervention for clients with recurrent aphthous stomatitis.

OTC topical anesthetic agents containing benzocaine in protective preparations may be used by clients with localized ulcerations. Benzocaine is an ester anesthetic; therefore, caution must be used when recommending these OTC products to clients with reported allergies to anesthetics. When oral pain is generalized, clients may use an OTC agent such as Chloraseptic® aa spray or Xylocaine® 2%, a viscous lidocaine prescription mouth rinse. Benadryl® x elixir and Benylin® x cough syrup may also provide topical anesthetic relief Because sprays and mouth rinses may anesthetize the palate and throat, clients should be advised to use caution when swallowing food to avoid aspiration, and to chew carefully to avoid trauma to the oral mucous membranes.

In cases of severe pain, such as that associated with mucositis, anesthetic agents may be mixed with OTC coating agents to provide lubrication and pain relief. Benadryl® elixir may be added in equal amounts to Maalox® e, Mylanta® m or Kaopectate® for symptomatic relief. Sucralfate (Carafate® bb), the prescription medication used to treat duodenal ulcers, may also be prepared as a 1 gm/15 ml suspension for use in this population. A pharmacist should be consulted to assist with the preparation of oral suspensions. Products used for pain control associated with oral ulcerations are listed in Table 7 and Table 8.

To replenish moisture to dry, cracked lips and to restore integrity of the epithelium, clients should be advised to use a topical water- based product, such as Oral BalanceÒ v or K-Y JellyÒ jj. These OTC products are widely available, inexpensive, and easy to use.Clients should be instructed to apply the product liberally throughout the day, and at bedtime. Clients should be carefully examined to detect the presence of a fungal infection which may contribute to dry, sore and cracked lips.

Intervention No. 7

Oral Hygiene Education

Clients with xerostomia present with increased plaque accumulation and gingival disease due to the loss of the antibacterial effects of saliva. However, increased plaque accumulation can also be attributed to the loss of the mechanical cleansing action of saliva and the loss of lubrication, both of which allow food to remain between and around the teeth. Further, changes in tooth structure from chemical erosion and mechanical abrasion, especially on root surfaces, facilitate plaque adherence, adding to the cycle of tooth and periodontal destruction.9

Dental hygienists working closely with clients can personalize daily oral hygiene regimens that are comprehensive, effective and realistic. Because xerostomic clients have many oral care needs, it is important to devise a care plan that will produce clinical results, which in turn, will promote continued compliance. Client motivation is an essential component of any oral hygiene self-care program, and the dental hygienist must continually monitor client participation in and effectiveness of the interventions prescribed.

Technological and scientific advances have produced chemotherapeutic agents and devices that enable clients to perform self oral hygiene care more easily than ever before, and the dental hygienist should encourage clients to take advantage of these technologies.68 Power-assisted devices, such as electric, rotary and sonic toothbrushes, enable clients to mechanically remove more plaque than conventional manual brushes. These devices provide greater bristle to tooth contact and improve access, especially for clients who are physically challenged 69,70,71,72,73,74, 75,76,77 Powered toothbrushes mechanically remove plaque that has already adhered to the tooth surface.

Oral irrigators are excellent adjuncts to powered toothbrushes, as these devices flush out food debris and unattached plaque bacteria between teeth and in gingival crevices, and can be used to deliver antimicrobial agents subgingivally to help control gingivitis. Various antimicrobiais can be delivered via irrigation, including chlorhexidine, Listerine® and stannous fluoride. For example, clients may use a Water Pik® jj to deliver Listerine® at and slightly below the gingival margin to help control gingivitis. This method has been shown to reduce both Polyphyromonas (Bacteroides) gingivalis and Actinobaccicillus actinomycetemcomitans in subjects over the course of a six week study period.78 Powered toothbrushes and oral irrigators are readily accessible and affordable, and when used correctly, are highly effective for plaque removal.

Interdental cleaning is essential for both dental caries prevention and gingival health.68 There are numerous interdental cleaning aids available on the market, and each has its own advantages and limitations. The most important aspect of counseling clients about interdental cleaning is advising them to find an aid they like and will use: this aid may be different from the one deemed "most ideal" or most preferred by the dental hygienist. It is helpful to have samples of aids for clients to try both at chairside and at home. Because there are so many interdental aids from which to choose, it is likely that experimentation will eventually satisfy each client's needs.

Salivary flow and the act of mastication help to clear the oral cavity of foods, including sugars and carbohydrates. Changes in salivary flow rates can remarkably slow the time required to clear sugars from the mouth, which is another cause for dental caries formation in xerostomic clients.9,79 Nutritional counseling, an important dental hygiene service, should emphasize reducing the time teeth are exposed to sugars and starches.14 Acidic beverages, such as soft drinks, sports drinks, and citric juices contribute to increased dental caries risk. The combined sugar content and acidity of these beverages contribute to enamel demineralization. As previously discussed, clients should be advised to use only sugarless chewing gum to neutralize plaque acids and to stimulate salivary flow. Clients with xerostomia, mucositis, or fungal infections may choose to limit the intake of citrus fruits, as well as acidic and/or spicy foods, which may be painful. Client counseling should focus on the importance of proper nutrition, and may require collaboration with or referral to a trained dietician.

Clients should also be given information about the benefits of smoking cessation. Xerostomic clients lack the protective effects of salivary mucins against carcinogens and toxins, and smoking further adds to oral dryness and irritation.9,11 As smoking is a primary environmental risk factor for periodontal disease and oral cancer, the dental hygienist should assess tobacco use during the comprehensive health history review, and make appropriate recommendations.80,81,82,83 A variety of products can be used to assist with smoking cessation, including OTC nicotine patches, nicotine chewing gum and the prescription drug Zyban® a.

Finally, xerostomic clients should be examined at frequent intervals, to assess their oral tissue status and monitor compliance with medication use and oral self care. Changes in both systemic and oral health status can be detected quickly and at an earlier stage of disease progression when clients are seen on a regular basis. Through periodic screenings and early treatment interventions, dental hygienists can help clients achieve and maintain good oral health and function.

Supplemental Activities:


(experimental learning activities)

  1. Visit the Websites from different product companies to learn about new products and technologies that are available for use with clients who are experiencing oral side effects from medication use.
  2. Use the computer to access the many drug databases available through the Internet. Learn about new medications and any known oral side effects. Share this information with clients and colleagues.
  3. Document recommendations made to clients experiencing oral side effects, and monitor clinical outcomes across time. Interview clients about their opinions as to the efficacy of the products/procedures recommended, personal likes and dislikes, and factors that influenced their compliance.
  4. Document an interesting or unusual clinical scenario as a case study for publication. Include intraoral photographs, charting, product recommendations and interventions. Provide a description of pre-intervention and post-intervention outcomes.

Key Terms

Adverse effects: harmful effects associated with drug use

Drug toxicity: toxin induced cellular damage and cell death

Drug hypersensitivity: allergic reaction that occurs when the drug or its metabolites trigger the immune system

Drug interactions: adverse effects that occur when one drug alters the effects/action of another

Idiosyncratic reactions: unusual and unpredictable responses to medications

Drug side effects: adverse effects that differ from the desired drug effect

Oral side effects: adverse effects that target the teeth, mucosa, salivary glands and underlying supporting structures of the oral cavity