Prescribed and Nonprescribed Medications: Assessment, Analysis, and Associated Dental Management Guidelines
The following are medications that should be evaluated during patient assessment:
- Prescribed medications
- Over-the-counter (OTC) medications
- Drugs associated with or causing allergic reactions
- Corticosteroids (discussed in Chapter 40)
- Recreational drugs
- Herbal medications
As discussed in Chapter 1, you must obtain a complete list of medications prescribed by the patient’s physician and determine the DDIs with the anesthetics, analgesics, and antibiotics (AAAs) used in dentistry. The ideal way to assess prescribed medications is presented in Chapter 2, where digoxin (Lanoxin) and theophylline (TheoDur) are discussed.
Review the history and determine the over-the-counter (OTC) medications the patient is taking.
Aspirin or NSAIDS
Aspirin permanently affects the platelet cyclo-oxygenase system causing decreased platelet cohesiveness. Always determine if the patient is taking the 81mg or the 325mg strength aspirin. Check with the patient’s physician if either aspirin strength can be stopped temporarily prior to major dentistry. Physicians prefer not to stop aspirin intake in high risk for thrombosis patients, and in such situations, the dental provider must control bleeding using local hemostatic materials. NSAIDS also affect the same system but the effect is temporary. The platelet function returns to normal once the NSAID has cleared the system.
Nasal Decongestants, Cough or Cold Preparations, and Appetite Suppressants
All these preparations contain sympathomimetic agents, epinephrine or neosynephrine. The epinephrine in local anesthetics can synergize with the sympathomimetic agents in these preparations and cause an epinephrine overdose-type reaction resulting in blood pressure elevation, especially if the patient is using the cough/cold preparations multiple times during the day. Obviously it is best to avoid routine dental treatment for the short term if the patient is too sick. However, if you have to treat the patient for a dental emergency, use 3% mepivacaine (Carbocaine) or 4% prilocaine HCL (Citanest Plain) instead.
Check for laxative use. Laxatives do not interfere with dental treatment when used in therapeutic doses. Do not prescribe codeine or other narcotic analgesics that cause constipation to a patient who is habitually on laxatives. Laxative overuse is not uncommon in patients with eating disorders, such as anorexia and bulimia. Laxative overuse or abuse can cause significant hypokalemia or low potassium level.
The normal serum potassium is 3.5–5.5 mEq/dL, and the patient becomes symptomatic in the presence of hypokalemia. Muscle cramps, muscle weakness, tingling numbness in the hands and feet, and irregular pulse can occur with hypokalemia. Do not give any local anesthetic during the hypokalemia state because cardiac arrhythmias could occur. Be aware that hypokalemia can also occur in a patient with a history of severe vomiting and/or diarrhea.
DRUGS CAUSING OR ASSOCIATED WITH ALLERGIES
Sulfites, bisulfites, sulpha antimicrobials, aspirin, NSAIDS, penicillins, cephalosporins, codeine, or morphine can all cause allergies, and you must determine the presence of an allergy history to these medications, before you begin any dental treatment.
Anaphylactic reactions can be mild, moderate, or severe. The longer it takes for reactions to occur, the better the prognosis. Acute reactions occur within the first hour of taking the drug. Most frequently, however, the reaction occurs within minutes after taking the drug.
Acute Anaphylactic Reaction
Anaphylaxis Diagnosis and Treatment
Anaphylaxis is highly likely when one of the following three criteria is fulfilled: