Dental Medication Changes

An Expert Interview With Peter Jacobs, DDS, PhD

Laird Harrison

October 29, 2012

SAN FRANCISCO, California — Editor's note: New drugs, guidelines, and disease patterns are changing the way dentists medicate their patients.

A presentation on medication was featured here at the American Dental Association 2012 Annual Session, held October 18 to 21. Medscape Medical News interviewed presenter Peter Jacobs, DDS, PhD, a general dentist and pharmacologist-toxicologist in San Francisco, California.

Medscape: What new drugs are becoming important in dentistry?

Dr. Jacobs: As far as new drugs on the market, it turns out there are not many. The drugs that work the best, such as the antibiotics penicillin and amoxicillin, are tried and true. But there are new ways of applying those drugs. The American Heart Association set its original guidelines for prophylaxis in heart patients in 1955. It has changed the guidelines 10 times in the last 50 years. Each time they have suggested that fewer and fewer patients need to be prophylaxed. The reason they have changed those guidelines is that you don't need antibiotics for most heart conditions, but patients with really severe heart conditions do need them. These people are at high risk of dying.

Medscape: What rules apply to patients with joint replacements?

Dr. Jacobs: Many patients have prosthetic joints. We're mostly talking about the knees and hips. The joints can be infected by bacteria [from] a foreign site, and the oral cavity is certainly a foreign site with lots of bacteria. The American Academy of Orthopaedic Surgeons has said patients with prosthetic joints should be prophylaxed before dental procedures to prevent those bacteria getting to that joint.

Medscape: Do patients with prosthetic joints need prophylaxis for the rest of their lives?

Dr. Jacobs: Many people have had a prosthetic joint for 10 years, and they've had no problem. The[se] guidelines are changing [too]. Dentists don't set these guidelines. They are set by orthopedic surgeons. Previously, if someone had no medical problems — they weren't immunosuppressed and they had no problem in the joint for the last 2 years — then they no longer needed to be prophylaxed. But in 2010, the American Academy of Orthopaedic Surgeons changed their guidelines, essentially setting it up such that anybody with a prosthetic joint needs to be prophylaxed for the rest of their lives. [Again,] the guidelines are changing, and they will probably change back as the scientific research is looked at to see exactly what the risks are. But at this point in time, they need to be prophylaxed for the rest of their lives.

Medscape: What else is changing about antibiotics?

Dr. Jacobs: Antibiotics should also usually be used when the patient has an obvious infection — some swelling, maybe even some pus coming out, maybe a little bit of a fever [or] swollen lymph nodes, and of course the necessary dental procedure, whether it's endodontic or periodontal. Antibiotics are finding a wider use in dentistry for other infections, such as osteonecrosis of the jaw secondary to antiresorptive drug therapy. The bisphosphonates are very common antiresorptive drugs. Antibiotics are now being used to manage those sorts of infections if they ensue.

Medscape: Are many general dentists prescribing antibiotics for osteonecrosis?

Dr. Jacobs: It's a complex disease. It didn't exist 4 or 5 years ago. With the advent of these antiresorptive drugs, people started noticing that patients taking them had a higher incidence of osteonecrosis infection, [which is] difficult...to control. As a general dentist, I would refer these cases out to a physician or a periodontist or an oral surgeon — someone who has advanced training in managing difficult oral infections.

Medscape: Should dentists be prepared to prescribe antiviral medications?

Dr. Jacobs: Dentists [can] certainly...prescribe antiviral drugs to eliminate herpetic infections. Seventy to 90% of the population has had an attack [of herpes simplex] when they were children, whether they knew it or not. About 20% to 40% of the adult population gets secondary attacks. After the primary attack, some of the viruses take up residence inside the DNA of the nerve cell, and those are the ones that cause secondary attacks. Usually, by the time a person gets to a dentist with a primary attack, nothing can be done.

Secondary attacks are where the dentist can be useful. There is something called preherpetic neuralgia. The antivirals are most effective as soon as a patient gets a secondary attack. If a patient comes in and says, "I have a herpes lesion," it's too far into the attack to do much about it. But usually they can feel a little bit of a tingling sensation before the lesion forms. As soon as the patient knows they're going to get an attack, that's when they should start the medication. And if a patient knows when they go skiing that they get a fever blister on the lips, they might ask for a prophylactic drug. They might easily stop the attacks.

Medscape: What drugs are effective for these viruses?

Dr. Jacobs: The classic drug for viral infections in dentistry is acyclovir. But now there is valacyclovir. Valacyclovir is better absorbed, so the patient doesn't have to take it as often. There is also an over-the-counter product, docosonol. They can smear that on a lesion, which prevents the viruses from infecting the next cell. The patient should have some antiviral medications on hand when the attack occurs. So the patient should be prescribed those medications ahead of time.

Medscape: We've talked about bacteria and viruses. What about fungus?

Dr. Jacobs: There are a variety of oral fungal infections. It turns out that half of us have normally living in our mouths fungal organisms, and when the balance is tipped in oral cavities that are dry or if the patient is taking an antibiotic, killing the bacteria, the funguses overgrow and cause a burning sensation or a strange taste. A burning sensation is uncommon for anything except a fungal infection. Then the dentist is available to prescribe antifungal medications. These are usually lozenges that dissolve slowly in the mouth and kill the fungal organisms. There are a number of medications; clotrimazole and mycostatin are 2 of the most common. The newest thing is to realize that the precipitating factors are so diverse.

Medscape: Are canker sores caused by a virus?

Dr. Jacobs: A lot of people get sores in the oral cavity. They may even bite their cheek, and it's sensitive for a day or so and goes away. But something that lasts longer, a sore in the cheek or under the tongue, is a canker sore or aphthous ulcer. There are little tiny ones and larger ones that interfere with eating and drinking. We don't fully understand what they are, but they seem to be an allergy where our bodies are attacking the insides of our mouths.

There are 3 ways to manage them. You can prevent them, which anybody would like to do but isn't always easy. Or you can cover them up with something like canker cover, which literally just covers them up and protects them from the fluids of the mouth while they heal. Or you can numb them. Benzocaine is the classic numbing agent.

As far as preventing is concerned, one of the things I recommend to my patients is to try eliminating sodium laurel sulfate. It's in all dental products that foam. One alternative is Biotene Dry Mouth Toothpaste. It's very neutral, has no foaming agents, no flavoring, but does have fluoride. There are other products that don't contain sodium laurel sulfate, so a patient just has to check the package to see if it's there.

Medscape: Should dentists be cautious of any other toothpaste ingredients?

Dr. Jacobs: Lots of toothpastes contain fluoride, but they are starting to add other ingredients to make them multipurpose. They may also put in a polishing agent. They may put in stannous ions. Stannous is a tin ion. Stannous fluoride is not only good at stopping decay, it's good at preventing inflammation, and it kills certain organisms. It's good for plaque and gingivitis. Other products have something called triclosan, also a disinfectant that kills certain organisms.

The dentist needs to look at the product that has the most ADA seals to find one what will be valuable for their patient. If you look at the seal, the product may have been given the seal for more than 1 purpose. For example, Colgate Total has 2 seals, one for antidecay and one for plaque and gingivitis, while Crest Pro-Health has seals for decay, plaque and gingivitis, halitosis, whitening, and sensitivity.

I always tell dentists to be aware of what the patient needs. If the patient has a decay problem but no plaque or gingivitis, then they just need fluoride. If they have a halitosis problem or a sensitivity problem, they should look around for products that solve all of that patient's problems.

Medscape: Should dentists be cautious of any other toothpaste ingredients?

Dr. Jacobs: These are all compounds that the US Food and Drug Administration approved and the ADA researched; so, they are safe and effective. That doesn't mean someone might not have an allergy to, say, peppermint, which is a flavoring agent. Or someone may react to one of the antitartar ingredients — they don't have an allergy, but it irritates their cheek, so layers of skin rub off.

Dr. Jacobs has disclosed no relevant financial relationships.

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