Adverse drug interactions in dentistry

According to the United States Food and Drug Administration web site, there are more than 15,000 currently approved prescription and over-the-counter drugs, diagnostics and intravenous supplementation products in the United States (78). Couple these with the hundreds of herbal and dietary supplements that undergo little if any scrutiny by the Food and Drug Administration (48), and it is no wonder that the potential for adverse drug interactions is a growing concern for all fields of patient care including dental medicine. To further complicate matters, common food products, such as grapefruit juice, that are consumed by many patients because of their reported cardiovascular and cancer-preventing benefits, have been involved in some of the most serious adverse drug interactions reported to date (19, 74, 158). There is no doubt that our patient population is consuming more and more drugs and herbal products. The geriatric dental population is increasing (75) and because of the presence of multiple disease states such as hypertension, congestive heart failure, diabetes, arthritis, and osteoporosis in these individuals, polypharmacy in this population is the norm (99, 182). In addition, decreases in cardiac output resulting in less blood flow and less drug being presented to the liver and kidney, decreases in hepatic and pre-hepatic drug metabolizing efficiency, decreases in renal excretory ability and increased receptor sensitivity to a variety of the central nervous system-acting drugs such as antidepressants, narcotics, and benzodiazepines, and a progressive decline in counter-regulatory (homeostatic) mechanisms make this population especially vulnerable to the adverse effects of drugs (232). Unlike 30 years ago, when many of these patients were coming to dental practices completely or partially edentulous, these patients are now maintaining their teeth longer and even when there is risk of tooth loss or there are edentulous spaces, many of these patients are opting for complex periodontal, implant, and restorative procedures over full or partial dentures (60). As a consequence, these patients need local anesthesia ⁄ vasoconstrictors, analgesics, anxiolytics, and antibiotics, which on occasion could adversely interact with a variety of the medications they are on. Even among young to middle-aged adults, the intake of certain prescription medications, especially those within the cardiovascular classes of drugs, is on the rise. With the new guidelines from the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, patients with what was previously considered normal or borderline blood pressure are now being placed on a variety of antihypertensive agents (45). Patients with concomitant cardiovascular risk factors such as diabetes are being more aggressively treated, with multi-drug regimens often being recommended at the initiation of antihypertensive therapy. Classes of drugs that did not exist 20 years ago are being widely administered to young and old alike. On December 29, 1987, fluoxetine (Prozac ) became the first selective serotonin reuptake inhibitor approved by the Food and Drug Administration for the treatment of adult depression (233). Today there are five selective serotonin reuptake inhibitors in the top 100 prescribed drugs in the United States (229). In addition to adult depression, they are being prescribed for a variety of psychiatric conditions including childhood depression, social anxiety disorder, general anxiety disorder, panic attacks, and obsessive–compulsive disorder. Because of their more recent arrival on the market compared to other drug classes, our knowledge of potential adverse drug interactions with these agents is still evolving. Like the geriatric patient population, the pediatric dental patients have their own unique physiology and anatomy compared to young adult patients that