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CLINICAL
The 20 most frequently prescribed drugs –
that your patients may be takingPhilip Atkin and Helen Rogers out-of-hospital prescription are immunomodulatory or biologic A key part of safe dental practice is knowing and understanding the drugs, both by cost and also number of prescriptions.
medical conditions patients will present with, and how these conditions In relation to community prescribing (including general and their medical management may impact on proposed dental medical practitioners) – which best describes what our patients treatment. An up to date and comprehensive medical history is an will present with, the following drugs form the top twenty (by essential part of this. The General Dental Council (GDC UK) in the numbers of prescriptions issued) – see table 2.
recent publication ‘Standards for the Dental Team1' included a lot of advice and information for dental registrants on their duties, as well as knowledge and understanding. Towards the front of the document is a list of things that patients should expect of their dental professional, and it includes the statement "That all aspects of their health and well-being will be considered and they will receive dental care that is appropriate for them." Health and well-being extends beyond dental health to include general health also. In another GDC publication "‘Preparing for Practice – Dental Team Learning Outcomes for Levothyroxine Sodium Registration2", the GDC defines what it is that each dental registrant needs to "cover the full range of skills, knowledge and behaviours needed to work in dental practice". There are learning outcomes common to all the dental registrant groups, and the two below are those most relevant to a knowledge and understanding of the medications patients may be taking on presentation to your surgery.
1.1.3 Explain general and systemic disease and their relevance to oral Metformin Hydrochloride 1.1.8 Describe the properties of relevant drugs and therapeutic agents and discuss their application to patient management Bisoprolol Fumarate Co-Codamol (Codeine Phos- Table 1. Relevant GDC learning outcomes for dental registrants Citalopram Hydrobromide What are the most frequently prescribed drugs?
Within the UK each country collects its own data and since England has the greatest number of prescriptions dispensed an examination of that data will reflect the majority of patients in the UK, and will likely mirror prescribing in the other three UK countries. In England the Health and Social Care Information Table 2: Top 20 prescribed drugs in England (by number of Centre publishes data on prescribing3, and the most recent data is from 2013. Hospital prescribing and dental prescribing data are also published, but this is less useful for the purposes of this article. Out of interest, however, the top two items of dental prescribing come from the British National Formulary (BNF) categories of ‘Infections' followed by ‘Nutrition and blood'. This is likely to reflect prescribing of antimicrobials to treat infections, followed by prescriptions for fluoride in its different forms. In hospital prescribing, half of the top ten drugs prescribed on an Volume 53 No 5 of 6 September 2014 Top 20 drugs and their dental relevance
gastric acid reflux, in severe cases there may be dental hard tissue Numbers 1 (simvastatin) and 10 (atorvastatin)
erosion to be seen and also complaints of a bad taste or burning sensation in the mouth.
These are both statins – prescribed to reduce serum cholesterol. This reflects that fact that many patients through diet and (lack Numbers 5 (rampiril), 6 (amlodipine), 13
of) exercise are at risk of atheroma and so arterial narrowing may (bendroflumethiazide), 14 (bisoprolol) and 18
occur. Complications of this can manifest as stroke, thrombosis or cardiac ischaemia (angina) or myocardial infarction (MI). These are all used in the management of hypertension, though Dental professionals need to be up to date on the emergency they have different mechanisms of action. Hypertension is often management of these conditions, and also be aware of the fairly a consequence of atheroma – which takes us back to aspirin and common interaction of imidazole antifungals (e.g. miconazole/ the statins above.
Daktarin®) with the statins leading to an increase in skeletal Ramipril is an angiotensin converting enzyme inhibitor (ACEI) muscle pain, cramps and even muscle damage. Prescribing for and has dental relevance in that the incidence of angioedema patients with oral candidosis needs to account for this.
(although rare) is increased in patients on this family of drugs. Numbers 2 (aspirin), 7 (paracetamol) and 15 (co-
This may present as lip, tongue or face swelling which appears rapidly over an hour or so, either spontaneously or following These are all analgesic medications. Aspirin is the number 2 manipulation of the orofacial tissues – such as in a visit to the drug, however it is most likely prescribed in large amounts for dentist/hygienist/therapist. It can be easy for the patient, and the those patients who have had a stroke or MI where the aspirin uninformed dental registrant, to confuse the angioedema with an is prescribed as 75mg rather than 300mg tablets and the effect allergic response to contact with a drug or dental material. is to reduce platelet adhesion and therefore small clots in those Amlodipine is a calcium channel blocker, and these drugs, in patients who have atherosclerosis – see statins above. The other some patients, can be associated with gingival hyperplasia and analgesics are most likely to be prescribed for management of overgrowth. Immaculate dental hygiene can help to reduce this pain, and may reflect the amount of chronic joint pain associated effect in susceptible individuals, and occasionally periodontal with osteo- and rheumatoid arthritis, both of which are more surgery is required to reduce the bulk of the fibrous gingival common in a population with an increasing average age. In tissue to allow dental restorative and hygiene measures to be terms of dentistry, limited mobility may affect people's ability to access dental surgeries, or with rheumatoid arthritis affecting the Bendroflumethiazide and furosemide are both diuretic drugs, joints of the hand – a reduced ability to use a toothbrush, dental which help to remove excess fluid and so improve hypertension floss and other oral hygiene aids.
and heart failure as well as reduce the work of the heart muscle Number 3 (levothyroxine)
– again relevant to those patients with angina. The effect of the This will be given as a replacement for those patients who either diuretics in removing excess fluid may manifest in reduced saliva have an underactive thyroid or who have had a thyroid gland production – resulting in tooth decay and gum disease. removed because of gland overactivity and need replacement. Bisoprolol is a beta-blocker – effectively capping the heart rate Much of thyroid disease is autoimmune mediated, and and reducing the work of the heart muscle. Again, the beta- autoimmune disease often presents in multiple sites in a single blockers are often prescribed in those patients with atheroma and patient – for example rheumatoid arthritis, with thyroid disease so at risk for angina, MI and stroke.
and Sjogren's syndrome. When a patient notes thyroxine on Number 8 (salbutamol)
their drug list, the dental professional needs to look out for other autoimmmune disease manifestations – and the dry mouth This drug is most often used with an inhaler (or nebuliser) associated with Sjogren's syndrome has immediate dental to allow for smooth muscle relaxation of the upper airways and relieve the symptoms of asthma and chronic obstructive pulmonary disease (COPD). Patients with asthma may well be Numbers 4 (omeprazole) and 9 (lansoprazole)
atopic, and also describe hayfever, eczema and other sensitivities These drugs are proton pump inhibitors (PPI) used to reduce such as to nickel. These patients may well also be more likely acid secretion in the stomach. This may be to reduce gastric and to be allergic to dental materials (latex gloves for example) and duodenal ulceration or to reduce acid reflux causing heartburn drugs used in dentistry – local anaesthetics and antibiotics. and they are also often prescribed alongside steroid tablets to Patients with airways disease will need special consideration prevent additional gastric mucosal irritation. It is important to for general anaesthetic and sedation, and again, severe asthma check the reason for the prescription with the patient. If the can present as an emergency in the dental surgery and an up reason is steroid tablets, this may reveal other systemic disease to date knowledge of its management is required for all dental important and relevant to dentistry, and also occasionally patients registrants. Patients with COPD may well be current or former on oral steroids undergoing minor oral surgery may need smokers, and so the risk of oral cancer may be increased and additional steroid supplementation. If the PPI is prescribed for suspicious oral mucosal lesions need to be carefully evaluated and referred where appropriate.
Finally, at number 20 on the list, is warfarin. This is an Number 11 (metformin)
anticoagulant drug which has been around for many years. Patients on warfarin may have had stroke, MI, deep An oral hypoglycaemic agent, it is commonly used in the vein thrombosis (DVT) or have recently had a heart valve management of type 2 diabetes. It is important to know how replacement. They are likely to be on many other drugs too. well the diabetes is controlled by the patient and that in some The anti-coagulant effect of warfarin is measured using the patients with type 2 diabetes, where the blood glucose remains international normalised ratio (INR). A high INR indicates an high despite the oral anticoagulants, treatment with insulin is increased bleeding tendency. Most patients will have a target INR also required. These patients, like those with type 1 diabetes, range of between 2 and 3, for indications such as previous stroke, are at risk from hypoglycaemia if the insulin is not matched DVT or heart valve replacement. The duration of the warfarin with dietary carbohydrate intake, and so an awareness of the treatment may be limited to a few months. Patients with an INR emergency management of hypoglycaemia in the dental surgery target range of 3 to 4 will often have had a mechanical heart is important. Both type 1 and type 2 diabetes are associated valve replacement and the warfarin will be used lifelong. The with atheroma and patients often have a history of angina and guidance for performing dental surgery on patients on warfarin is hypertension, and may also be taking some of the drugs already regularly updated4 and currently there should not need to be any mentioned above.
alteration in warfarin dose for simple dental surgery in primary Number 12 (colecalciferol)
care so long as the INR is 4 or less.
This is a vitamin D supplement and is used in the management of vitamin D deficiency - which is a diagnosis on the increase. A knowledge and understanding of commonly prescribed drugs Vitamin D may be prescribed in children and young adults, and their effects and uses is required by the GDC, and this is but is often prescribed for post-menopausal females at risk of so dental registrants, as healthcare professionals, can plan and osteoporosis to be taken alone or alongside bisphosphonate drugs perform safe and effective treatments for their patients.
to reduce the risk of bone fracture. Vitamin D supplement on the drug list should flag up the possibility of the patient taking a bisphosphonate drug as well. The immediate dental relevance of About the authors: Dr Helen Rogers is a lecturer/honorary bisphosphonates is the risk of developing bisphosphonate-related registrar in oral medicine and Dr Phil Atkin is a consultant hon/ osteonecrosis of the jaws (BRONJ/BONJ/ONJ) which can senior lecturer in oral medicine in Cardiff dental hospital and either occur spontaneously or following dental treatment such as school. As well as teaching and practising in oral medicine, both extraction or root surface debridement.
are involved in the delivery of the teaching, and assessment Numbers 16 (citalopram) and 19 (amitriptyline)
in human health and disease/clinical medical sciences to undergraduate dental students.
These are both antidepressant drugs (albeit in different families: SSRI and tricyclic antidepressants respectively), but are also Address for correspondence: [email protected] commonly used in the management of chronic pain such as bone and joint pain, irritable bowel and some orofacial pains (e.g. trigeminal neuralgia, chronic idiopathic orofacial pain, burning mouth syndrome). The principal relationship to dental disease Standards for the Dental Team www.gdc-uk.org Published September 2013 is the common side-effect of these drugs in reducing saliva Preparing for Practice – Dental Team Learning Outcomes for Registration flow. The effects of a dry mouth on promoting dental decay www.gdc-uk.org Published 2012 and plaque with gingival inflammation are often obvious, and increased oral hygiene measures and sometimes the use of topical fluoride is indicated.
Number 17 (amoxicillin)
This is an antimicrobial agent. It features highly in dental prescribing for the management of orofacial infections, and is used by medical practitioners for the treatment of a wide range of infections, especially respiratory infections. It is a broad-spectrum antibiotic and has multiple indications. Patients who repeatedly receive antibiotics for various infections may become sensitised and develop allergies, and the overuse of amoxicillin and similar antibiotics can also lead to the development of resistant bacteria, including MRSA.
Number 20 (warfarin)
Volume 53 No 5 of 6 September 2014

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