Understanding Medication Effects on Teeth
October 1, 2023 / Category: Peterabasdds
Many individuals rely on medications to manage various conditions. However, while these medications can be beneficial, they may also have effects on oral health. From common over-the-counter remedies to prescription drugs, the substances we ingest can sometimes have unintended consequences for our teeth and gums. Let us learn more about these effects and ways to maintain a healthy smile even while managing your health with necessary treatments.
According to the Centers for Disease Control and Prevention (CDC), nearly 7 in 10 adults between the ages of 40 and 79 used at least one prescription drug in the past 30 days in the United States, and approximately 1 in 5 used at least five prescription drugs. Those medications can be a godsend, keeping our ticker pumping, our glucose levels low, our airways clear during brutal allergy seasons, and our depressive moods at bay. But they can be murder on our mouths.
Here we’ve listed the common culprits for oral health problems linked to medications, as well as other drugs that can potentially cause the same issues. Plus, find out ways to prevent and treat the conditions. Learn how to stay healthy — while keeping your teeth, gums (and more) happy.
1. Some anticoagulants commonly prescribed for heart attack and stroke prevention
What they can cause: Excessive bleeding — usually from the gums or tooth sockets — can occur during or after invasive procedures, such as a tooth extraction or gum surgery. Because the blood doesn’t clot normally, it may be difficult to stop the flow, which can lead to severe blood loss and, in rare cases, hospitalization.
Common culprits: Prescription medications that can lead to an increased risk of bleeding are anticoagulants, commonly prescribed as part of a heart attack and stroke prevention strategy for patients with heart disease, deep vein thrombosis, pulmonary embolisms or atrial fibrillation. Commonly prescribed: warfarin (Coumadin), rivaroxaban (Xarelto) and apixaban (Eliquis). These drugs are also used by those who’ve recently undergone knee or hip replacement.
Other meds that may lead to bleeding: antiplatelet meds such as clopidogrel (Plavix), which prevent platelets (or blood cells) in your bloodstream from clumping together and are primarily used to prevent the recurrence of blood clots following a heart attack or stroke.
Come clean. To avoid complications, let your dentist or oral surgeon know what medications you’re taking — yes, that includes low-dose aspirin (sometimes prescribed as a mild blood thinner) and herbal supplements, which can actually interfere with the metabolism of some of these drugs. “Imagine you’re on aspirin for prevention of cardiac events, then buy a gingko supplement because you want to improve your memory,” says dentist Mahnaz Fatahzadeh, professor and interim director of the Division of Oral Diagnosis at Rutgers School of Dental Medicine. “Depending on how much you take, or what brand, it could actually exacerbate the bleeding aspirin can cause. When you’re on any medication, it’s important not to take supplements without first consulting with your physician,” she adds.
Take measures. Depending on the dental procedure, consult with your prescribing doctor to see if temporarily stopping the medication or reducing the dosage is an appropriate precautionary measure. One approach, for example, may be to make sure the patient doesn’t take the medication for a certain number of days prior to their dental visit. However, says dentist Stephen Shuman, professor and director of the Oral Health Services for Older Adults Program at the University of Minnesota School of Dentistry, “We used to think that we should take patients off these medications before dental procedures because we were more worried about the potential bleeding than the possible effects on blood clotting. Now research tells us that it’s the other way around. It’s safer to try and do the procedures and leave people on those medications. Because if we take them off, they’re at an increased risk for an adverse event,” he says. Dentists can take precautions during the procedure to help manage bleeding. For example, they can use a hemostatic dressing or agent, such as gauze or an absorbent gelatin sponge, around the extraction site to promote clotting and then carefully suture the wound.
2. Gummy vitamins and other medications with added sugar
What they can cause: Some medications have sugar added to mask the flavor and make them more palatable. While a bit of sweetness may make things easier on the taste buds, it’s bad news for your teeth — particularly if medications are taken for a long period of time. If you consume sugar frequently, this reduces the pH level of the saliva, causing it to become more acidic. Frequent pH drops in the saliva can cause the mineral structure of the tooth to break down — and, over time, cause cavities.
Culprits: Sugar is frequently an added ingredient in chewable vitamins and antacid tablets (such as Tums) and in syrup-based concoctions (such as cough suppressants). Liquid antibiotics (amoxicillin, for example), formulated for those who have a tough time swallowing pills, may also contain sugar. Particularly lethal: sticky gummy vitamins that glom onto your teeth, as well as long-lasting cough drops. Both provide an acid bath for your choppers.
What’s more: “We know there is a relationship between diabetes and periodontal disease,” says pharmacist Kimberly Sanders, assistant professor at the University of North Carolina Eshelman School of Pharmacy. But, she notes, some diabetes drugs — such as metformin (Fortamet) or some of the newer injectable options, like liraglutide (Victoza) — can cause gastrointestinal upset. “That can lead to acid reflux or even nausea and vomiting. If you’re starting on those, you may experience potential oral health problems because of the enamel-eroding acid the medications produce.”
Go sugar-free. Ask your health care provider or pharmacist to see if there is a sugar-free alternative to your medication (though swapping may not be an option).
Double down on oral hygiene. “Brush with a fluoride treatment and use a fluoride mouth rinse to make sure you’re getting extra protection,” says dentist Donald Chi, professor of oral health sciences and associate dean for research at the University of Washington. “And be sure to schedule regular dental appointments.”
Boost your health care regimen. Follow a diet that’s low in sugar and starches. And if you smoke, stop. (According to the CDC, adults 65 and older who smoke cigarettes are twice as likely to have untreated tooth decay, compared with those who never puffed.)
Careful with the C. Acidic vitamins, such as vitamin C, provide a triple whammy. “They contain sugar and are also acidic, so they can eat away at tooth enamel,” Sanders says. “They can also increase the amount of acid in your stomach, and that can lead to acid reflux, which can also lead to erosion of tooth enamel.” Rinse your mouth after taking anything acidic. Baking soda is ideal because it neutralizes the acid. (Add 1 teaspoon to a glass of water.)
Take your meds with a meal. That is, if they can be taken with food rather than in between meals. Since you’re more likely to brush after eating, the sugar won’t linger.
3. Some antibacterial mouth rinses
What they can cause: Discolored teeth (in the form of yellowish-brown stains) and an increase in tartar. That dullness, by the way, is usually caused by the interaction of the antiseptic with chromogens, pigmented compounds found in foods (berries and coffee have high concentrations).
Common culprits: “The one we see most often is chlorhexidine, an antiseptic mouth rinse,” Fatahzadeh says. Other potential troublemakers: antihistamines (like Benadryl) and anti-hypertension medications — including ACE inhibitors such as benazepril (Lotensin), calcium channel blockers such as amlodipine (Norvasc) and felodipine (Plendil), and beta-blockers such as metoprolol succinate (Lopressor) — all of which can reduce saliva production, making it harder to get rid of stain-causing food and debris in the mouth. Inhaled corticosteroids, such as fluticasone (Flonase), can also damage tooth enamel because of the acid content in the spray. Cholestyramine (Prevalite), a powder-formulated cholesterol med designed to be mixed in a beverage, can result in discoloration when sipped slowly.
Clean up. “It’s important to distinguish the type of discoloration that your medications are causing,” Chi says. Extrinsic discoloration on the surface of the tooth — from mouth rinses containing chlorhexidine, for example — can be cleaned off at your next dental hygiene visit or with a whitening treatment.
Go deep. For more stubborn stains, your dentist may recommend microabrasion (a procedure that involves using abrasive agents to remove a small amount of enamel from your teeth to make stains less noticeable), bonding or porcelain veneers.
4. Calcium channel blockers used to lower blood pressure in patients with hypertension
What they can cause: Gingival overgrowth, a buildup of swollen gum tissue that begins to grow over teeth, creating a friendly environment for bacteria. Unsightly, for sure, but it can also lead to discomfort and pain, especially if that overgrowth gets in the way of chewing.
Common culprits: Calcium channel blockers such as amlodipine (Norvasc) and felodipine (Plendil) can be frequent offenders. This condition is also associated with anti-seizure medications, such as phenytoin (Phenytek), and with immunosuppressive agents, such as cyclosporine (Neoral and Gengraf) and methotrexate (Otrexup and Trexall), which prevent the immune system from damaging healthy cells and are usually taken by people with organ transplants or by those with autoimmune diseases such as severe rheumatoid or psoriatic arthritis. “Gingival overgrowth doesn’t usually happen from the drugs alone,” Shuman points out. “It’s usually the drug in combination with tissue irritation from things like plaque. When they take these medications and maintain good hygiene, we don’t seem to see problems.”
Swap in a new drug. Work with your physician to see if there is an alternative medication that might work.
Up your dental visits. More frequent cleanings (every four months) can also help lower your chances of developing this condition. Patients who already have overgrowth, in particular, should increase their oral hygiene regimen. It won’t reverse the problem, but plaque control can prevent it from getting worse.
Get it trimmed. If the problem persists, there are periodontal procedures that can remove overgrown gum tissue. One is a gingivectomy, which involves surgically cutting away diseased gum tissue around the teeth. “However, this is a temporary fix,” Chi says. “The medication the patient is taking will often lead to continued overgrowth, and over time the gum tissue will come back again.”
5. Oral bisphosphonates, commonly prescribed for osteoporosis to strengthen bones
What it can cause: Osteonecrosis of the jaw (ONJ) is a rare but potentially serious complication of oral surgery that causes death of the jawbone tissue.
Common culprits: Antiresorptive drugs such as oral bisphosphonates — alendronate (Fosamax), risedronate (Actonel and Atelvia) and ibandronate (Boniva) — are commonly prescribed for osteoporosis to strengthen bones. They are also used in cancer patients to limit or prevent the spread of cancer to the bones, such as bone metastasis in breast cancer or multiple myeloma. “These drugs can be livesaving and quality-of-life-preserving,” says dentist Thomas Schlieve, M.D., associate professor in the Department of Surgery at UT Southwestern Medical Center in Dallas. “But they can have one side effect: osteonecrosis of the jaw.”
ONJ is a potential side effect of dental surgery while taking these medications. The condition typically occurs after a tooth extraction or some other invasive dental work, which may leave a bit of your jawbone exposed. If the gum tissue is slow to heal or fails to heal entirely, that area of jawbone is left exposed, doesn’t get blood flow and dies. In the early stages, “Osteonecrosis can be asymptomatic, to the point where you don’t even know you have it. Maybe they just feel a rough spot with their tongue,” Schlieve says. If it progresses, the dead bone becomes infected and painful and, in later stages, can spread beyond the bone that supports your teeth to the nerves.
Be proactive. Talk to your doctor about potential alternatives to bisphosphonate drugs that may pose less risk. Before scheduling dental work, discuss your osteoporosis drug history with your oral surgeon and doctor. Typically, the longer a patient is on this medication, the higher the risk is for ONJ. Proactive dental care before and during antiresorptive drug therapy can reduce the risk of developing ONJ by as much as 50 percent.
Keep it clean. Treatment depends on the stage of ONJ at diagnosis. Once all of the bone tissue dies, it can’t be revived. But if caught early, doctors can help reduce bone loss. In the early stages, approximately half of patients will heal through nonsurgical debridement. This involves gently scrubbing the exposed bone twice a day with a prescription-strength antiseptic mouth rinse and a soft baby toothbrush or Q-tip. This helps removes bacteria off of the surface of the bone to prevent it from getting infected and to aid in tissue healing. It also helps loosen things up: Over time, the gums regrow underneath the dead bone and it pops right out.
Consider surgery. Those who don’t heal experience increased pain and recurrent infections, requiring surgery. An oral surgeon who has experience with ONJ removes the dead bone, along with any teeth that may be touching it and a bit of tissue, to make sure no diseased cells remain.
6. Some antidepressants and anxiety meds
What it can cause: Dry mouth that can increase risk for cavities, gum disease and canker sores. Saliva not only lubricates the mouth, but it also neutralizes the acid produced in the mouth. But as we age, our salivary glands become less active, making us more susceptible to tooth decay. Add to the mix the medications that further reduce our salivary flow, and this can lead to trouble. Without good salivary flow, food can accumulate, putting you at risk for cavities, gum disease, bad breath and fungal infections. And since the mouth’s mucosal lining is protected by that coating of saliva, you can get canker sores more frequently.
Not having enough saliva can affect taste perception, notes Fatahzadeh, because food particles have to be dissolved in the saliva to stimulate the receptors in the mouth. “A patient may have a tendency to put more [seasoning] in their food,” she says. “Imagine someone who is hypertensive putting more salt in their diet, or a diabetic putting more sugar in their drink.”
Common culprits: Dry mouth is a potential side effect of literally hundreds of medications that interrupt the secretion of saliva. In particular, drugs that alter our central nervous system, including anxiety meds such as escitalopram (Lexapro) and sertraline (Zoloft), and antidepressants such as fluoxetine (Prozac) and alprazolam (Xanax). “They can suppress the production of acetylcholine, a neurotransmitter that stimulates the production of saliva by the central nervous system,” Sanders says.
Also on the list: meds to treat urinary incontinence or an overactive bladder, such as oxybutynin chloride (Ditropan XL) and oxybutynin (Oxytrol); Parkinson’s disease medications, such as levodopa, also called L-dopa (Sinemet); blood pressure and heart medications, including ACE inhibitors such as lisinopril (Prinivil and Zestril), enalapril (Innovace) and benazepril (Lotensin); and beta-blockers such as metoprolol succinate (Lopressor and Toprol XL). Plus, not surprisingly, diuretics which help rid your body of water and salt to bring down blood pressure, such as furosemide (Lasix). Radiation therapy and chemotherapy may also damage the salivary glands.
If this is a serious problem, perhaps the medication can be changed. If that isn’t possible, the patient needs a strategy to minimize symptoms.
Chew on it. Stimulate the salivary glands and keep your mouth moisturized by chomping on sugar-free gum or sucking on sugar-free candy periodically throughout the day.
Moisturize your mouth. Keep a water bottle nearby and take sips throughout the day, Fatahzadeh says. “Fill a spray bottle with water and spritz your mouth to create a coating on the mucosa.” Limit your caffeine intake: Consuming a lot of coffee, tea or soda can make dry mouth worse. Rinsing your mouth in the morning and at night with an alcohol-free mouthwash after brushing your teeth can help reduce dry mouth. Mouthwashes that contain xylitol (such as Act Dry Mouth Mouthwash) have been shown to promote saliva production.
Try an over-the-counter saliva substitute. Products such as Allday Dry Mouth Spray can help keep the mouth lubricated. For severe dry mouth, physicians may prescribe medications such as Salagen or Evoxac to help stimulate saliva production.
Turn on the humidifier. “If you’re a mouth breather who wakes up feeling parched,” Fatahzadeh says, “put a humidifier next to your bed to add moisture to the air and to make your mouth less dry when you wake up.”
7. Nonsteroidal anti-inflammatory drugs (NSAIDs) used to relieve pain and reduce inflammation
What they can cause: Painful soft tissue reactions, including mucositis (inflammation of the mucous membrane that lines the inside of the mouth), and ulcerated sores, which can occur inside the mouth or on the tongue.
Common culprits: NSAIDs such as ibuprofen and aspirin, for starters. Other potential irritants include hypoglycemic agents for type 2 diabetes such as metformin (Fortamet or Glucophage); beta-blockers, including metoprolol succinate (Toprol XL) and bisoprolol (Zebeta), used by those with angina, high blood pressure and abnormal heart rhythm to help the heart beat more slowly; and immunosuppressive agents, among them prednisone (Deltasone) and methotrexate (Otrexup and Trexall), which prevent the immune system from damaging healthy cells and are usually taken by people with autoimmune diseases such as rheumatoid arthritis, multiple sclerosis and inflammatory bowel disease.
Chemotherapy and radiation therapy may cause changes in the lining of the mouth and the salivary glands, upsetting the healthy balance of bacteria. In addition: “Quick-dissolving tablets that dissolve under, or on top of, your tongue can cause irritation at the site,” Sanders says. Among them: nitroglycerine tablets (Nitrostat) used to prevent angina (chest pain) caused by coronary artery disease, anti-nausea medications such as ondansetron (Zofran), or benzodiazepines such as lorazepam (Ativan), which target anxiety or sleeping problems.
Keep your mouth in good shape. Good oral care can help prevent or decrease the severity of mucositis as well as infections. See your dentist regularly to make sure your gums are healthy. “Mucositis can make dental problems, such as preexisting gingivitis, even more painful and cause more bleeding when you brush,” Fatahzadeh says. “That can interfere with oral hygiene, and you may end up getting cavities on top of everything else.” Start by brushing with a soft-bristle brush, which is easy on your gums. Still experiencing sensitivity? Swap your toothbrush for a foam swab.
Gentle, please. “Many toothpastes have additives like anti-plaque, anti-tartar and whitening ingredients, which can cause adverse reactions in some people,” says dentist Mark Wenzel, clinical assistant professor in the Division of Restorative and Prosthetic Dentistry at The Ohio State University Wexner Medical Center. Strong minty or cinnamon flavoring agents, dyes, gritty particles and foaming agents such as sodium lauryl sulfate can also irritate the mouth. Choose a mild formula — maybe one with baking soda. “Do adequate brushing with a toothpaste that has plain old fluoride, and you’re going to be fine,” Wenzel notes. While you’re at it, stick with an alcohol-free mouthwash, which is less likely to cause a burning sensation.
Eat (and drink) smart. Avoid spicy, salty or hot foods and drinks until your mouth heals. Hard, sharp munchies (think potato chips or crackers) can also hurt tissue that’s swollen. Stick with soft foods (or moisten with broth or sauces). Also, steer clear of alcohol, drinks with caffeine and acidic juices.
Ease the sting. Cryotherapy, as in sucking on ice chips, is sometimes used by cancer patients to prevent mucositis caused by chemo treatments. Try the same thing at home, allowing the chips to slowly dissolve in your mouth. Or create a soothing homemade mouth rinse by mixing a teaspoon of baking soda and a teaspoon of salt in 4 cups of warm water. Swish the solution around in your mouth, then spit it out. Keep the remaining solution in a covered container at room temperature and use throughout the day. (Bonus: It helps keep the inflamed tissue clean.)
Stop puffing. The heat and chemicals in tobacco irritate the mucous membranes.
Get an Rx. Your physician or dentist may prescribe a rinse or a topical coating agent, such as hydrocortisone buccal tablets (they stick gently to the inside of your mouth, releasing hydrocortisone as they dissolve), to coat the mucosa, forming a protective barrier to minimize any pain you might feel while eating or drinking.
Bring out the big guns. “If someone has mouth sores from chemotherapy, there’s a product your dentist or physician can prescribe, called ‘magic mouthwash,’ ” Shuman says. “It’s kind of a catchall that contains a mixture of medications, such as Benadryl and Maalox, along with other ingredients — for example, an anesthetic, antibiotic or an antifungal med to coat the tissues.”
Prioritize your oral health alongside your overall well-being. Consult with Dr. Peter Abas to develop a comprehensive oral care plan. Schedule your appointment today at 949.586.1127. Don’t forget to join our IG community: @peterabasdds.