Clinical tips: oral health

toothbrush and pills

Jarrod McMaugh takes a look at the impact different medicines can have on oral and dental health

Pharmacists are a great resource for people when they have a question about dental health, and can advise on minor annoyances that can be treated simply, or larger issues that require a referral to a dentist.

An area that many of our patients don’t consider is how their medications impact on their oral and dental health. Pharmacists can proactively assist with oral health by making people aware of these impacts, and ensuring that the advice they give is up to date with current evidence.

Medications can impact on oral health by reducing saliva production, directly impacting on dentine formation, altering gum tissue growth, altering the immune response, or changing bone metabolism.

At the same time, oral health can impact on the way medications are absorbed or consumed. For instance, buccally absorbed medications may be delayed by poor saliva production or cause discomfort to damaged teeth and infected gums.

Counselling a patient on the impact of medication on dental health becomes an important consideration with long term use. It may not be ideal to explain potential impacts on the mouth when a new medication is prescribed, as the risk of information overload gets in the way of complete counselling. Instead, pharmacists can prioritise these issues on subsequent dispensing while monitoring compliance and side effects.

Impact on saliva production

Many medications impact saliva production. Dysfunction of saliva production is one of the leading causes of dental caries, gum disease, and halitosis.

Antihistamines, amphetamines, decongestants, chemotherapeutic agents, and methadone are all associated with changes in the production of saliva.

Other lifestyle factors will compound this impact: smoking, caffeine, and some health conditions such as sleep apnoea will amplify the impact of dry mouth.

Patients should be advised to utilise unsweetened chewing gums, enzyme-rich mouth washes, or artificial saliva replacements if they notice that they are experiencing regular dry mouth

Impact on dentine

Dentine production and integrity can be impacted by medications that create an acidic environment in a similar way to acidic food. Some medications may also integrate into dentine as it is formed, causing discolouration or weakness.

Medications associated with dentine damage include inhaled medications, antibiotics from the tetracycline family, and aspirin that is directly dissolved on a toothache.

Inhaled medications provide a particular trap for pharmacist advice, as we will often counsel patient to rinse their mouth out after using inhaled corticosteroids. This “rinsing” may involve the incorrect advice to brush the teeth after using an inhaled medication.

Brushing at this time can increase abrasive damage to the dentine due to the acidic environment and temporary integration of inhalant particles into the dentine. The correct advice is to rinse with water only, and to avoid brushing for half an hour after using inhaled medications.

Impact on gum tissue

Medications can impact on gum health, leading to overgrowth (hyperplasia), receding gums, irritation, and sensitivity.

Some anti-seizure medications, calcium channel blockers, and oral contraceptives have been associated with changes in gum growth.

In cases of hyperplasia, a new medication may be required, while receding gums and sensitivity will usually require a greater attention to oral care to prevent bleeding and exposure of the tooth root.

Impact on immune response

Chemotherapeutic agents and disease-modifying anti-rheumatic drugs that impact on the immune response can affect dental health through several mechanisms.

Clearly a direct impact on the immune system will allow for commensal microorganisms or pathogens to take hold in the mouth. In addition, these medications may suppress saliva production or gum growth by altering the growth of epithelial tissue involved in these processes.

In these situations, it is not only important to advise people that their medication may impact on their dental and oral health, but also the way they brush their teeth may need to be modified to ensure they do not irritate the gums or abrade the teeth.

Impact on bone metabolism

Bisphosphonates are well understood to alter the ability of bone to respond to a fracture, as the process of removing the damaged surface around a fracture requires osteoclasts to function normally, before new bone can form in the repair process.

Tooth extractions require this same process, as the jaw bone needs to be re-modelled around the point from which the tooth was removed. The result is an increased risk of jaw damage or necrosis following a tooth extraction in people who have used anti-resorptive therapies; even when therapy has been ceased years prior to the tooth extraction.

The current advice is for people who require anti-resorptive therapy to have an assessment of their dental health prior to initiation of therapy, and to have any extractions done prior to treatment if required.

Pharmacists can assist with this message by discussing a patient’s recent dental care when filling a first prescription for bisphosphonates, and advising them to consult with their dentist before therapy begins.

Jarrod McMaugh is a community pharmacy practitioner with Capital Chemist in the northern suburbs of Melbourne. He has extensive experience in developing and delivering professional services in the community pharmacy setting.

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