Guidance in Specific Populations: Pregnancy, Elderly and Substance Abuse
Pregnancy and Breastfeeding
Oral health care, including having dental radiographs taken and being given local anesthesia, is safe at any point during pregnancy. Further, the American Dental Association and the American Congress (formerly “College”) of Obstetricians and Gynecologists (ACOG) agree that emergency treatments, such as extractions, root canals or restorations can be safely performed during pregnancy and that delaying treatment may result in more complex problems.
When treating pregnant patients, it might be helpful to reach out to the obstetrician to develop a working relationship should consultation be needed later. Questions you might ask include:
• When is the expected delivery date?
• Is this a high-risk pregnancy? If so, are there any special concerns or contraindications?
Questions about the local anesthetics or antibiotics used in dentistry are common when treating this patient population. According to a 2012 JADA article by Donaldson and Goodchild (see Suggested Reading List), options considered safe for use in these situations include certain local anesthetics (with or without epinephrine), most antibiotics, and some pain relievers (see Table 1).
* In the case of combination products (such as oxycodone with acetaminophen), the safety with respect to either pregnancy or breastfeeding is dependent on the higher-risk moiety. In the example of oxycodone with acetaminophen, the combination of these two drugs should be used with caution, because the oxycodone moiety carries a higher risk than the acetaminophen moiety.
† In April 2017, the U.S. Food and Drug Administration issued a warning that recommends against use of codeine and tramadol in children younger than 12 years, also extending the warning against use to breastfeeding women because of possible harm to infants.
‡ Oral steroids should not be withheld from patients with acute severe asthma.
§ Ibuprofen is representative of all nonsteroidal anti-inflammatory drugs. In breastfeeding patients, avoid cyclooxygenase selective inhibitors such as celecoxib, as few data regarding their safe use in this population are available, and avoid doses of aspirin higher than 100 milligrams because of risk of platelet dysfunction and Reye syndrome.
¶ Antibiotic use during pregnancy: The patient should receive the full adult dose and for the usual length of treatment. Serious infections should be treated aggressively. Penicillins and cephalosporins are considered safe. Use higher-dose regimens (such as cephalexin 500 mg three times per day rather than 250 mg three times per day), as they are cleared from the system more quickly because of the increase in glomerular filtration rate in pregnancy.
# Antibiotic use during breastfeeding: These agents may cause altered bowel flora and, thus, diarrhea in the baby. If the infant develops a fever, the clinician should take into account maternal antibiotic treatment.
** Adapted with permission from Donaldson M, Goodchild JH. Pregnancy, breast-feeding and drugs used in dentistry. J Am Dent Assoc 2012;143(8):858-71.
Providing needed dental treatment, managing oral infection, and controlling pain are essential functions of dentists for helping patients maintain overall health during pregnancy. For a pregnant patient requiring dental care, the agents prescribed should be especially evaluated for potential risks to the mother and/or fetus. The decision to administer a specific drug requires that the benefits outweigh the potential risks of therapy.
Historically, manufacturers have relied on an alphabetical system to communicate the safety of medications for use with pregnant patients (Table 2). In 2015, the US. Food & Drug Administration began phasing out that system for prescription drugs, replacing it with a narrative section in the package insert that discusses the benefits and risks of using a particular medication with this population. The new system will be phased-in, with a full compliance date of 2020. After 2020, the alphabetical system will continue to be used for over-the-counter medications.
2 | Medication Use During Breastfeeding
Drugs that negatively impact pregnancy are not necessarily unsafe during breastfeeding. According to the American Academy of Pediatrics Committee Report on Drugs, many drugs “should not affect the milk supply or breast-feeding infant.” (see Suggested Reading List).
One option women have when faced with taking medications is to pump and save milk prior to the dental appointment; then, pump and discard the milk produced after use of medication. Donaldson and Goodchild suggest that this approach is especially useful when drugs with short half-lives are used. They report that it takes approximately four half-lives to eliminate more than 90 percent of most medications. (see Suggested Reading List).
Questions also often arise about medication use by patients who are lactating. Most medication product inserts have information related to use during lactation. The National Library of Medicine also provides a searchable database (LactMed) on this topic.
3 | Analgesia and Anesthesia Safety Issues
Many analgesics are available over-the-counter, providing easy access and perhaps even the implication that these medications are safe when taken during pregnancy or breastfeeding. According to Donaldson and Goodchild, however, some of these medications can be harmful to the fetus, mother or infant if used during these periods (see Suggested Reading List). For example, they report that ibuprofen has been known to have detrimental effects when taken during pregnancy such as problems in fetal implantation, childbirth and maternal pulmonary hypertension. Aspirin has been linked to development of fetal organs outside the abdominal wall when taken during pregnancy, according to the authors.
Aspirin also presents risks when used during breastfeeding, including bleeding and Reye Syndrome, and thus, should be avoided. According the American Academy of Pediatrics Committee on Drugs, acetaminophen is a better option for pain relief for women who are breast feeding.
Nitrous oxide is classified as a pregnancy risk group Category C medication, meaning that there is a risk of fetal harm if administered during pregnancy. It is recommended that pregnant women, both patients and staff, avoid exposure to nitrous oxide.
| Suggested Reading
• Donaldson M, Goodchild JH. Pregnancy, breast-feeding and drugs used in dentistry. J Am Dent Assoc 2012;143(8):858-71.
• American Association of Pediatrics Committee on Drugs. The Transfer of Drugs and Other Chemicals into Human Milk. Pediatrics 2001;108(3):776-789.
• ACOG Committee Opinion No. 569: oral health care during pregnancy and through the lifespan. Obstet Gynecol 2013;122(2 Pt 1):417-22.
• Steinberg BJ, Hilton IV, Iida H, Samelson R. Oral health and dental care during pregnancy. Dent Clin North Am 2013;57(2):195-210.
• Hagai A, Diav-Citrin O, Shechtman S, Ornoy A. Pregnancy outcome after in utero exposure to local anesthetics as part of dental treatment: A prospective comparative cohort study. J Am Dent Assoc 2015;146(8):572-80.
• Mendia J, Cuddy MA, Moore PA. Drug therapy for the pregnant dental patient. Compend Contin Educ Dent 2012;33(8):568-70, 72, 74-6 passim; quiz 79, 96.
According to data from National Health and Nutrition Examination Survey (NHANES), 39% of people aged 65 years and older reported using 5 or more prescription drugs (“polypharmacy”) in the prior 30 days during the years 2011 through 2012. Ninety percent of people 65 years of age and older reported using any prescription drug in the prior 30 days. The high prevalence of polypharmacy among older adults may lead to inappropriate drug use, medication errors, drug interactions or adverse drug reactions. According to Ouanounou and Haasthe, the average older adult takes 4 or 5 prescription drugs; in addition, these individuals may also be taking 2 or 3 over-the-counter (OTC) medications (see Suggested Reading List). A review of older dental patients’ medical history and current medications, both prescription and OTC medications/supplements, should be done regularly.
1 | Medication Considerations
Drugs most commonly prescribed in elderly patients include “statin” drugs for hypercholesterolemia; antihypertensive agents; analgesics; drugs for endocrine dysfunction, including thyroid and diabetes medications; antiplatelet agents or anticoagulants; drugs for respiratory conditions (e.g., albuterol); antidepressants; antibiotics; and drugs for gastroesophageal reflux disease and acid reflux. The most frequently taken OTC medications by older adults include analgesics, laxatives, vitamins, and minerals.
Older adults frequently show an exaggerated response to central nervous system drugs, partly resulting from an age-related decline in central nervous system function and partly resulting from increased sensitivity to certain benzodiazepines, general anesthetics, and opioids. The American Geriatrics Society has published a 2015 update to the Beers Criteria for potentially inappropriate medication use in older adults have been found to be associated with poor health outcomes, including confusion, falls, and mortality (see Suggested Reading List). One change of note to the 2015 Beers Criteria includes the addition of opioids to the category of central nervous system medications that should be avoided in individuals with a history of falls or fractures. Check out the Latest Prescribing Recommendations in the Elderly before prescribing or administering medications to your senior patients, which can be found here:
2 | Oral Health and General Dental Considerations
Xerostomia affects 30% of patients older than 65 years and up to 40% of patients older than 80 years; this is primarily an adverse effect of medication(s), although it can also result from comorbid conditions such as diabetes, Alzheimer’s disease, or Parkinson’s disease.
Xerostomia, while common among older patients, is more likely to result from medication use. Dry mouth can lead to mucositis, caries, cracked lips, and fissured tongue. Stein and Alaboe suggest that individuals with dry mouth consider drinking or at least sipping regular water throughout the day and limiting alcoholic beverages and beverages high in sugar or caffeine, such as juices, sodas, teas or coffee (especially sweetened) (see Suggested Reading List).
Because cardiovascular disease is common among older individuals, it has been suggested by Ouanounou and Haas that the dose of epinephrine contained in anesthetics should be limited to a maximum of 0.04 mg (see Suggested Reading List). The authors recommend that even without a history of overt cardiovascular disease, the use of epinephrine in older adult patients should be minimized because of the expected effect of aging on the heart. They recommend monitoring blood pressure and heart rate when considering multiple administrations of epinephrine-containing local anesthetic in the older adult population.
| Suggested Reading
• Ouanounou A, Haas DA. Pharmacotherapy for the elderly dental patient. J Can Dent Assoc 2015;80:f18.
• Fitzgerald J, Epstein JB, Donaldson M, et al. Outpatient medication use and implications for dental care: guidance for contemporary dental practice. J Can Dent Assoc 2015;81:f10.
• Bowie MW, Slattum PW. Pharmacodynamics in older adults: a review. Am J Geriatr Pharmacother 2007;5(3):263-303.
• American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc 2015.
• Razak PA, Richard KM, Thankachan RP, et al. Geriatric oral health: a review article. J Int Oral Health 2014;6(6):110-6.
• Preston AJ. Dental management of the elderly patient. Dent Update 2012;39(2):141-3.
• Stein P, Aalboe J. Dental care in the frail older adult: special considerations and recommendations. J Calif Dent Assoc 2015;43(7):363-8.45.
Box 1. Pain Management in Substance Abuse Disorders
Clinical Considerations Prior to Administering or Prescribing to Patients with a History of Substance Abuse Disorders*
Q: Is the medication in the class of medications or substances that was/is the patient’s preferred substance of abuse?
A: If yes, do you absolutely need to administer or prescribe this medication? (Addiction IS NOT a contraindication to prescribe the medication if the benefits outweigh the risks.)
Q: Is the patient in a treatment program for drug or alcohol addiction or under a treatment center/prescriber contract for pain or anxiety management?
A: If yes, dental practitioners optimally should consult with the treatment center or practitioner enforcing the contract to discuss preferred treatment options.
Q: Will the medication being administered result in a positive drug screen that potentially could compromise treatment contracts?
A: If yes, dental practitioners and patients should discuss this issue with personnel responsible for the treatment contract before the procedure when possible.
[Nonsteroidal anti-inflammatory drugs] remain the first-line oral agents of choice for the management of acute pain in dental procedures unless otherwise contraindicated.
For patients with a history of alcohol, benzodiazepine, or barbiturate addition, controlled substances such as benzodiazepines or barbiturates are not recommended for light sedation or anxiolysis due to the potential for stimulating similar pathways in the brain that promote craving.
Alternative agents, such as antihistamines (diphenhydramine or hydroxyzine), may be considered if light sedation is required. Anecdotally, patients in recovery from alcohol or benzodiazepine addiction have reported a significant increase in cravings after receiving nitrous oxide inhalation for light sedation or anxiolysis.