Deedee L. McClain, RDH, MS; James D. Bader, DDS, MPH; Susan J. Daniel, RDH, MS; Darlene H. Sams, RDH, MEd
Gingival effects of prescription medications among adult dental patients The relationship between self-repotted medication use (exposure to one or more drugs with anticipated gingival effect - antidepressants, diuretics, antihypertensives, hormones) and four measures of gingival conditions (plaque index, gingival index, calculus index, maximum CPITN score) was examined among 594 patients in 35 dental practices in two North Carolina counties. Patients with long-term medication use were compared to patients without long-term use on four measures of gingival condition. When controlling for sex and age within age group, medication use was a significant predictor ( P < 0.05) for elevated gingival and plaque index scores among the white less than 65 group. For the white 65+ group (N = go), medication use was not a significant predictor for any index score.
t is commonly believed that medications can adversely affect gingival and periodontal health.’T2Some medications directly affect the oral tissues by producing soft tissue piginentation and ulceration.’” Others indirectly affect the oral tissues by causing impairment of the salivary glands or disturbing the normal oral flora.’,* There is an obvious need to assess the typical changes in periodontal status associated with medication use. Most reports of tissue changes have been based on individual case history documentation. Although these case reports show that certain drugs affect some patients adversely, the extent to which periodontal health is affected among a population of patients with long-term medication use found in general practices is unknown. This study determined if clinically obvious periodontal status effects of medication use are present in regularly attending adult dental patients. Several classes of commonly prescribed medications have gingival and periodontal effects. Oral contraceptives can cause hypertrophy of the gingival tissue^.^,^ Antihypertensives have caused xerostomia, salivary gland enlargement, and salivary gland pain with excessive or prolonged use by the patient.’,2,4-6 These drugs inhibit the normal salivation process by altering fluid and electrolyte balance. Diuretics have been cited as a group of drugs that may also cause xerostomia.’,5,h These drugs also affect fluid and electrolyte balance, and generally have a minor effect in decreasing salivary flow. Antidepressants and antipsychotics play a major role in the Not only occurrence of xerostomia.’,2,s,6 do they reduce salivary flow, but they
also may cause salivary gland swelling or ~ i a l o s i sAnother .~ side-effect of longterm use of some antipsychotics may be bluish-grey discoloration of the oral muco~a.’,’,~ Almost one-half of this type of medication with a definite xerostomic effect is composed of mood altering drugs such as tricyclic antidepressants, antipsychotics, sedatives, and hypnotics.?,’Finally, anti-inflammatory drugs have been linked with pain and swelling of the salivary glands.2 The most common link among these drug groups is a tendency for patients to develop some degree of xerostomia with long-term use. Decreased salivary flow can lead to increased irritation of the oral tissues and, possibly, the development of some degree of periodontal disease due to an increased rate of plaque accumulation.K
Methods The analyses reported here are based on oral examinations and medication histories of regularly attending patients in 35 general practices in two North Carolina counties. These practices were participating in a project that assessed the effects of continuing education on the prevention and treatment of periodontal disease. A sample of 80 patient records was randomly chosen in each of 36 dental practices.‘ To be selected, patients must have visited the office in 4 of the previous 5 years. Patients from this sample were invited to participate in clinical examinations to be performed in their practitioners’ offices. Patients who reported diabetes, epilepsy, uncontrolled hypertension, or long-term antibiotic therapy were excluded. At the beginning of the study, 1,092 pa-
Special Care in Dentistry, Vol l lNo l 1991 15
tients were examined to establish baseline data. The number of patients examined per practice ranged from 28 to 34. At the second examination, 1 year later, 35 of the original 36 practices were still participating in the study. Of the 1,092 patients, 831 returned for a second examination. The results of these 1-year examinations form the basis of this report. The examinations, described in detail by McFall and others,Y."'-i2 included four measures of periodontal health: the Silness and Loe Plaque Index,"' the Loe and Silness Gingival Index," the NIDR Calculus Index,I2and the Community Periodontal Index of Treatment Needs (CPITN).'3The plaque, gingival, and calculus indexes were scored on the mesiofacial and facial aspects of the Ramfjord teeth. The CPITN was based on probing all surfaces of all teeth. The score for a patient's worst sextant was used in the CPITN analyses only to characterize periodontal status. The same examiner saw the patient at each examination. Patients' medications were identified by questionnaire and follow-up interview. At both examinations, the same medical history questions were used to address illnesses and medications. If patients reported an illness, examiners were instructed to inquire about the use of medications. The forms requested drug names, and examiners were instructed to discover the purpose of the drug. Patients were included in the analyses reported here only if the baseline and 1 year medication histories were the same. There were eight patients with long-term drug use who also were undergoing a single, short-term antibiotic regimen at baseline. These patients were included because a single regimen of antibiotic therapy would not cause any deliterious effects to the gingival tissues. Of the 831 patients who returned for a second examination, only 653 met the criteria for inclusion in the study. Four hundred seventy-three (72%)of these patients reported no regular drug use ("no expected effect"), and 180 (28%)patients reported taking the same drugs at both examinations. These patients constituted the group for analyses ("the expected adverse effect group"). As noted, no patients on
16 Special Care in Dentistry, Vol 11No 1 1991
long-term antibiotic therapy were admitted to the study. The sample was divided into nine mutually exclusive drug categories that represented the most frequent combinations of drug use among the patients. Six categories of drugs with expected adverse effects were combined for a total of 135 patients. The remaining three categories of drugs with no expected adverse effects were combined for a total of 518 patients. Table1 shows the distribution of patients within these categories. Medications were evenly distributed between the < 65 and 65+ age groups with the exception of "oral contraceptives and hormones" which were prevalent in the < 65 group. Patients taking anti-inflammatory medications were included in this no-effect group, rather than being excluded from the study. Although these drugs may have a beneficial effect on gingival inflammation, Table 1. Collapsed drug categories
No effect No drugs
473
Other medications
29
Anti-inflammatory only
16
Total
518
Expected effect Antihypertensives only
52
Diuretics only
27
Antidepressants only
10
Oral contraceptives and other hormones
23
Antihypertensives and diuretics
12
Antidepressants and anything
such an effect was considered similar to effects of improved oral hygiene. Furthermore, the anti-inflammatory effect would counteract any putative xero-stomic effects associated with certain medications in this category. Thus, these patients are still legitimate members of the no-adverse-effect group. The category, other medications, combined two drug groups. They were medications used in the treatment of gastrointestinal ulcers (n = 3 ) and also thyroid disorders (n = 26). Because no significant adverse periodontal effects have been noted from the use of these drugs, they were included in the no-adverse-effect group. Patients were grouped by age and race into four groups for all final analyses. Table 2 shows the distribution of all patients by age group (less than 65,65 and older) and by race (white and nonwhite). The majority of patients were in the white, younger than 65 group. Because there were only four patients in the 65 and older, nonwhite category, only descriptive analysis of this category was attempted. For each of the remaining three age and race groupings, regression analyses were used to estimate adjusted mean scores for each of the four periodontal health measures. These scores were adjusted for gender and age within age group. Before final runs, first order interaction terms were examined and found to be nonsignificant for all analyses for both the 65 and older as well as the younger than 65 white patient groups. For the nonwhite patients younger than 65, drug group interactions were found with both gender and age for each of the four periodontal outcome analyses. Table 2. Distribution of subjects by age and race.
N
%
White
Gingival effects of prescription medications among adult dental patients The relationship between self-repotted medication use (exposure to one or more drugs with anticipated gingival effect - antidepressants, diuretics, antihypertensives, hormones) and four measures of gingival conditions (plaque index, gingival index, calculus index, maximum CPITN score) was examined among 594 patients in 35 dental practices in two North Carolina counties. Patients with long-term medication use were compared to patients without long-term use on four measures of gingival condition. When controlling for sex and age within age group, medication use was a significant predictor ( P < 0.05) for elevated gingival and plaque index scores among the white less than 65 group. For the white 65+ group (N = go), medication use was not a significant predictor for any index score.
t is commonly believed that medications can adversely affect gingival and periodontal health.’T2Some medications directly affect the oral tissues by producing soft tissue piginentation and ulceration.’” Others indirectly affect the oral tissues by causing impairment of the salivary glands or disturbing the normal oral flora.’,* There is an obvious need to assess the typical changes in periodontal status associated with medication use. Most reports of tissue changes have been based on individual case history documentation. Although these case reports show that certain drugs affect some patients adversely, the extent to which periodontal health is affected among a population of patients with long-term medication use found in general practices is unknown. This study determined if clinically obvious periodontal status effects of medication use are present in regularly attending adult dental patients. Several classes of commonly prescribed medications have gingival and periodontal effects. Oral contraceptives can cause hypertrophy of the gingival tissue^.^,^ Antihypertensives have caused xerostomia, salivary gland enlargement, and salivary gland pain with excessive or prolonged use by the patient.’,2,4-6 These drugs inhibit the normal salivation process by altering fluid and electrolyte balance. Diuretics have been cited as a group of drugs that may also cause xerostomia.’,5,h These drugs also affect fluid and electrolyte balance, and generally have a minor effect in decreasing salivary flow. Antidepressants and antipsychotics play a major role in the Not only occurrence of xerostomia.’,2,s,6 do they reduce salivary flow, but they
also may cause salivary gland swelling or ~ i a l o s i sAnother .~ side-effect of longterm use of some antipsychotics may be bluish-grey discoloration of the oral muco~a.’,’,~ Almost one-half of this type of medication with a definite xerostomic effect is composed of mood altering drugs such as tricyclic antidepressants, antipsychotics, sedatives, and hypnotics.?,’Finally, anti-inflammatory drugs have been linked with pain and swelling of the salivary glands.2 The most common link among these drug groups is a tendency for patients to develop some degree of xerostomia with long-term use. Decreased salivary flow can lead to increased irritation of the oral tissues and, possibly, the development of some degree of periodontal disease due to an increased rate of plaque accumulation.K
Methods The analyses reported here are based on oral examinations and medication histories of regularly attending patients in 35 general practices in two North Carolina counties. These practices were participating in a project that assessed the effects of continuing education on the prevention and treatment of periodontal disease. A sample of 80 patient records was randomly chosen in each of 36 dental practices.‘ To be selected, patients must have visited the office in 4 of the previous 5 years. Patients from this sample were invited to participate in clinical examinations to be performed in their practitioners’ offices. Patients who reported diabetes, epilepsy, uncontrolled hypertension, or long-term antibiotic therapy were excluded. At the beginning of the study, 1,092 pa-
Special Care in Dentistry, Vol l lNo l 1991 15
tients were examined to establish baseline data. The number of patients examined per practice ranged from 28 to 34. At the second examination, 1 year later, 35 of the original 36 practices were still participating in the study. Of the 1,092 patients, 831 returned for a second examination. The results of these 1-year examinations form the basis of this report. The examinations, described in detail by McFall and others,Y."'-i2 included four measures of periodontal health: the Silness and Loe Plaque Index,"' the Loe and Silness Gingival Index," the NIDR Calculus Index,I2and the Community Periodontal Index of Treatment Needs (CPITN).'3The plaque, gingival, and calculus indexes were scored on the mesiofacial and facial aspects of the Ramfjord teeth. The CPITN was based on probing all surfaces of all teeth. The score for a patient's worst sextant was used in the CPITN analyses only to characterize periodontal status. The same examiner saw the patient at each examination. Patients' medications were identified by questionnaire and follow-up interview. At both examinations, the same medical history questions were used to address illnesses and medications. If patients reported an illness, examiners were instructed to inquire about the use of medications. The forms requested drug names, and examiners were instructed to discover the purpose of the drug. Patients were included in the analyses reported here only if the baseline and 1 year medication histories were the same. There were eight patients with long-term drug use who also were undergoing a single, short-term antibiotic regimen at baseline. These patients were included because a single regimen of antibiotic therapy would not cause any deliterious effects to the gingival tissues. Of the 831 patients who returned for a second examination, only 653 met the criteria for inclusion in the study. Four hundred seventy-three (72%)of these patients reported no regular drug use ("no expected effect"), and 180 (28%)patients reported taking the same drugs at both examinations. These patients constituted the group for analyses ("the expected adverse effect group"). As noted, no patients on
16 Special Care in Dentistry, Vol 11No 1 1991
long-term antibiotic therapy were admitted to the study. The sample was divided into nine mutually exclusive drug categories that represented the most frequent combinations of drug use among the patients. Six categories of drugs with expected adverse effects were combined for a total of 135 patients. The remaining three categories of drugs with no expected adverse effects were combined for a total of 518 patients. Table1 shows the distribution of patients within these categories. Medications were evenly distributed between the < 65 and 65+ age groups with the exception of "oral contraceptives and hormones" which were prevalent in the < 65 group. Patients taking anti-inflammatory medications were included in this no-effect group, rather than being excluded from the study. Although these drugs may have a beneficial effect on gingival inflammation, Table 1. Collapsed drug categories
No effect No drugs
473
Other medications
29
Anti-inflammatory only
16
Total
518
Expected effect Antihypertensives only
52
Diuretics only
27
Antidepressants only
10
Oral contraceptives and other hormones
23
Antihypertensives and diuretics
12
Antidepressants and anything
such an effect was considered similar to effects of improved oral hygiene. Furthermore, the anti-inflammatory effect would counteract any putative xero-stomic effects associated with certain medications in this category. Thus, these patients are still legitimate members of the no-adverse-effect group. The category, other medications, combined two drug groups. They were medications used in the treatment of gastrointestinal ulcers (n = 3 ) and also thyroid disorders (n = 26). Because no significant adverse periodontal effects have been noted from the use of these drugs, they were included in the no-adverse-effect group. Patients were grouped by age and race into four groups for all final analyses. Table 2 shows the distribution of all patients by age group (less than 65,65 and older) and by race (white and nonwhite). The majority of patients were in the white, younger than 65 group. Because there were only four patients in the 65 and older, nonwhite category, only descriptive analysis of this category was attempted. For each of the remaining three age and race groupings, regression analyses were used to estimate adjusted mean scores for each of the four periodontal health measures. These scores were adjusted for gender and age within age group. Before final runs, first order interaction terms were examined and found to be nonsignificant for all analyses for both the 65 and older as well as the younger than 65 white patient groups. For the nonwhite patients younger than 65, drug group interactions were found with both gender and age for each of the four periodontal outcome analyses. Table 2. Distribution of subjects by age and race.
N
%
White
