Oral adverse effects of gastrointestinal drugs and considerations for dental management in patients with gastrointestinal disorders.

Gastrointestinal disease is associated with alterations in the mouth or influence the course of the dental diseases, and the dental health care workers are expected to recognize, diagnose, and treat oral conditions associated with gastrointestinal diseases and also provide safe and appropriate dental care for afflicted individuals. Drugs used in the management of these diseases result in oral adverse effects and also are known to interact with those prescribed during dental care. Hence, this article has reviewed the drug considerations and guidelines for drug use during dental management of patients with gastrointestinal diseases.

The various diseases affecting the body as a whole are associated with alterations in the mouth or influence the course of the dental diseases. Gastrointestinal (GI) disease is not an exception and dental health care workers are expected to recognize, diagnose, and treat oral conditions associated with GI diseases and also provide safe and appropriate dental care for afflicted individuals. So, dentists are typically concerned with homeostasis, risk of infection, drug actions-interactions, and the patient's ability to withstand stress and trauma of dental procedures.[1]

Drug treatment of GI diseases was previously limited to the use of antacids, anticholinergics, antispasmodics, cathartics, and laxatives. Since the past decade, histamine H2-receptor antagonists (e.g. cimetidine, ranitidine, and more recently, famotidine and nizatidine) have revolutionized the treatment of peptic acid disorders. Currently, muscarinic M1-receptor antagonists (e.g. pirenzepine), proton pump inhibitors (PPIs; e.g. omeprazole), prostaglandin analogues, site-protective drugs (e.g. colloidal bismuth subcitrate and sucralfate), and newer antiemetics with prokinetic properties (e.g. metoclopramide, domperidone, and cisapride) have also been introduced in the management of GI motility disturbances, and new anti-inflammatory salicylates (e.g. olsalazine and mesalazine) have been developed for the treatment of chronic inflammatory bowel diseases (IBD). Diphenoxylate and loperamide have been used as nonspecific antidiarrheal agents.[2]

Some of the oral adverse effects resulting from these medications include dry mouth (PPIs, sucralfate, anticholinergics and pirenzepine), Erythema Multiforme (ranitidine,omeprazole) and loss of taste.[3] Numerous medications, including anti-inflammatory and sulfa containing preparations, that are commonly used to manage IBD patients have been reported to cause oral lichenoid reactions.[45] Super infection with Candida albicans in IBD patients may be a reaction to the bacteriostatic effect of sulfasalazine.[6]

Drug Considerations

During dental management, drug history should consider history of usage of GI drugs, in particular, corticosteroids or other immunosuppressant drugs, within the last 12 months; the need for antibiotics or to determine the infectious nature of the disease; the medications, dosages, and the likelihood of adverse effects of drugs taken by the patient and the need for additional medications; a change in medication to protect the patient's health during dental treatment; or any other special precautions required.[7]

Use of H2-blockers before dental treatment is beneficial in patients with gastroesophageal reflux. Patients taking cimetidine or other H2-blockers may experience a toxic reaction to lidocaine or other amide local anesthetics if the LA is injected intravascularly. Cimetidine and ranitidine have occasionally been associated with thrombocytopenia and may compete with antibiotics or antifungal medications.[1] Antacids impair the absorption of tetracycline, oral iron, fluoride, ciprofloxacin, erythromycin and metronidazole. Cimetidine also alters the blood flow to the liver and can enhance the duration of action of other medications. Under such circumstances, dosages of analgesics metabolized in the liver may require adjustment.[8]

In patients with peptic ulcer disease, management of dental caries in those with long history of dry mouth secondary to drugs is of utmost importance. However, the commonly used sialogogues (pilocarpine, cevimeline) may be contraindicated due to their parasympathomimetic action causing increased acid production in the stomach. Other measures to manage dry mouth may need to be instituted.

If a patient with known history of ulcerative colitis seeks dental care, considerations related to glucocorticosteroid use include blood pressure measurement, in-office blood glucose measurement, physician's consent to understand the patient's medical status, careful patient position in the dental chair, and advice to the patient for dietary calcium intake to prevent fractures due to osteoporosis secondary to long-term steroid use. Patients undergoing surgery may require supplemental glucocorticoids to prevent adrenal crisis.[8] Majority of the patients with antibiotic-induced diarrhea and pseudomembranous enterocolitis, though are without oral complaints, may neglect oral health. Hence, strict oral hygiene instructions and chlorhexidine rinses should be prescribed to manage the oral infections locally and limit the need for systemic antibiotics. However, itching and facial swelling including the tongue, lips, and mouth can be seen as one of the allergic reactions in patients taking bismuth subsalicylate, which needs appropriate referral regarding change in medication.[1]

In patients with eating disorders, antacids as a mouth rinse after vomiting may help to neutralize the acid introduced into the oral cavity. Chemoprevention using nonsteroidal anti-inflammatory drug (NSAIDs) sulindac in patients with Gardner's syndrome may have oral side effects and also may include a reduction in platelet aggregation, increasing the bleeding time after invasive dental treatment.[7]

Guidelines for Drug Use

Anesthesia guidelines

Local anesthesia can be used safely in majority of patients with GI disease except in those with severe liver disease who may be unable to detoxify large dose of amide type LA.

Alcoholics often require an increased dose of a local anesthetic agent to control pain adequately.

Use small doses of amide type local anesthetics or substitute with an ester type anesthetic.

Supplement local anesthetic with nitrous oxide analgesia.

Analgesia guidelines

Aspirin and other NSAIDs (ibuprofen, indomethacin, and naproxen) should be avoided in patients with peptic ulcer disease, as these exacerbate ulceration, cause GI distress and bleeding. Acetaminophen and compounded acetaminophen preparations are safe.

Frequent prescribing of narcotics to patients with chronic inflammatory conditions should be avoided.

Analgesics contraindicated in liver disease include aspirin, codeine, indomethacin, mefenemic acid, meperidine, NSAIDs, opioids, and acetaminophen (in large doses). These drugs contribute to an increased antiplatelet effect, and acetaminophen is hepatotoxic and should be avoided in large dose in chronic alcoholics and in those with severe liver disease. Alternative analgesics include codeine, cyclooxygenase 2 (COX-2) inhibitors (celecoxib, rofecoxib), hydrocodone, and oxycodone.

Antibiotic guidelines

Antibiotic in a patient with GI disease should be carefully prescribed and monitored. Improper dosage can result in less than optimal antibiotic blood levels and in the spread or non-regression of orofacial infections and periodontal disease.

Penicillin can be used without any problem in these patients as long as the patients are not hypersensitive to the drug.

Antibiotics should be taken 2 h before or 2 h after the ingestion of antacids containing aluminum and magnesium.

Antibiotics should be used cautiously in the elderly and debilitated, who are susceptible to pseudomembranous enterocolitis.

Sulfasalazine interferes with folate metabolism and supplemental folic acid may be needed, especially if macrocytic anemia is revealed in a complete blood count.

Calcithromycin, clindamycin, co-amoxiclav, and metronidazole can be given in lower doses than normal. A disulfiram-like reaction occurs when metronidazole is administered to a patient who has ingested alcohol. Culture and sensitivity testing is recommended whenever oral infection is present. Certain antimicrobials are contracindicated in liver disease [Table 1].

Table 1

Antimicrobials contraindicated and alternatives in patients with liver disease

Other drug guidelines

Patients taking immunosuppressive agents (azathioprine) in ulcerative colitis might be expected to have changes in WBC and RBC counts. These should be ascertained before embarking on surgical procedures.

Certain sedatives (diazepam, barbiturates) and general anesthetics (halothane) impair detoxification in hepatic disease and should be used cautiously.

Conclusion

Medical and dental aspects are both inseparable in patient management. The dentist's referral of patients with GI disease to the physician/gastroenterologist in particular can reduce mortality and morbidity. Hurry, worry, and hot curry being the commonest causes of gastric hyperacidity and other GI disturbances, antacids are widely used as over-the-counter drugs. Many such patients seeking for dental care is quite common, which stresses the need for detailed drug history during dental management.[9] A knowledge of wide variety of drugs used to treat GI disorders and their interactions with commonly prescribed drugs in dentistry is required before providing dental care.