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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 7  |  Issue : 1  |  Page : 24-27

Medication use for glaucoma contributing to a high caries risk


1 Department of Preventive Dentistry, Faculty of Dentistry, Lagos State University College of Medicine, Lagos, Nigeria
2 Department of Restorative Dentistry, Lagos State University Teaching Hospital, Lagos, Nigeria

Date of Submission04-May-2019
Date of Acceptance29-Apr-2019
Date of Web Publication06-Jan-2020

Correspondence Address:
Dr. Afolabi Oyapero
Department of Preventive Dentistry, Faculty of Dentistry, Lagos State University College of Medicine, Ikeja, Lagos
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijcd.ijcd_2_19

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  Abstract 


Dental caries is a chronic, transmissible disease of multifactorial etiology. There are a number of factors involved in the process of caries development. Xerostomia, resulting from medication use, may act synergistically with other known caries risk factors and indicators. We present a case report of a patient with high caries risk complicated by reduced salivary flow due to medications used in the treatment of glaucoma (Brimodin and Xalacom). A 36-year-old woman presented was referred to the Preventive Dentistry Clinic of the Lagos State University Teaching Hospital, Ikeja, Nigeria, on account of a 3-week history of toothache in the upper right quadrant. She had a high caries risk and a decayed, missing, and filled teeth index of 19. Consumption of cariogenic meals, poor plaque control, and treatment of glaucoma since childhood, with xerogenic medication, including xalacom and brimodin were determined to be part of the multifactorial etiology in this case. After relief of pain through pulp extirpation, the patient motivation and counseling on caries process, the need for good oral hygiene, and proper diet were done. Scaling and polishing were also done in addition to fluoride therapy and chemical plaque control. Improvement of salivary flow with the use of sugar-free chewing gum, artificial saliva, and frequent sipping of small quantities of water was also prescribed while the patient was referred to the restorative and oral surgery units for extraction of retained roots, composite fillings, and denture fabrication. Patients that present to any dental clinic with multiple carious lesions must be reviewed by the preventive dentistry specialists and have their caries risk assessed. It is also imperative that ophthalmologists include a dental consultation in the overall management of their patients, especially when they prescribe medication that has known oral side effects.

Keywords: Dental caries, glaucoma, medication, risk factors


How to cite this article:
Oyapero A, Amadasun CO, Olagundoye OO. Medication use for glaucoma contributing to a high caries risk. Int J Community Dent 2019;7:24-7

How to cite this URL:
Oyapero A, Amadasun CO, Olagundoye OO. Medication use for glaucoma contributing to a high caries risk. Int J Community Dent [serial online] 2019 [cited 2020 Sep 26];7:24-7. Available from: http://www.ijcommdent.com/text.asp?2019/7/1/24/275196




  Introduction Top


Dental caries is a chronic, transmissible disease of multifactorial etiology. There are a number of factors involved in the process of caries development. It is, however, the interaction of three major factors: pathogenic microflora (plaque), a substrate (cariogenic diet), and host susceptibility (teeth and saliva) described by the Keyes' three-circle diagram[1] that are the primary causes of the caries process.[2] Saliva is a chief protective factor in the oral cavity providing defense for oral hard and soft tissues and support for other critical oral functions.[3] In addition to its role in digestion, saliva serves several other functions, such as cleansing the oral cavity, facilitating digestion and deglutition, protecting oral tissues from physical and microbial insults, maintaining a neutral pH, and preventing tooth demineralization.[3]

The antimicrobial properties of saliva result from a variety of salivary proteins that inhibit the adherence and growth of viruses and bacteria.[4] Salivary proteins and mucins also contribute to the lubrication and coating of oral tissues, protecting the oral mucosa from chemical, microbial, and physical injuries. Reductions in salivary output can, however, result from many systemic diseases, medical interventions, and a host of medications.[5] Certain medications used in the treatment of systemic conditions may reduce the salivary function and secretory output,[6] leading to a diminishing of the antimicrobial, buffering, remineralizing, and cleansing properties of saliva. Complications of salivary hypofunction include an increased risk of oral infections, mucosal pain and friability, difficulties with chewing, swallowing and speaking, as well as rapid and severe dental caries. Xerostomia resulting from medication use may thus act synergistically with other known caries risk factors and indicator.

We present a case report of a patient with a high caries risk and complicated by reduced salivary flow due to a medication used in the treatment of glaucoma (brimodin and xalacom).


  Case Report Top


A 36-year-old woman presented was referred to the Preventive Dentistry Clinic of the Lagos State University Teaching Hospital, Ikeja, Nigeria, on account of a 3-week history of toothache in the upper right quadrant. There was, however, no history of facial swelling. Her dental history revealed that she has had multiple carious lesions and frequent tooth extractions. She also gave a history of a dry mouth. She brushes daily in the morning using a medium bristle toothbrush using the vertical scrub technique and with a fluoride-containing toothpaste. She is a volunteer social worker who is married but yet to conceive. She occasionally consumes refined carbohydrates in the form of biscuits, sticky sweets, and carbonated soft drinks. Her medical history revealed that she has had glaucoma since childhood, had eye surgery 12 years previously, and had been on xalacom, brimodin, and dorzolamide medication for over 15 years.

On extraoral examination, she was not pale, anicteric, and there was no obvious facial asymmetry. Both temporomandibular joints were palpable, moved synchronously, nontender, with no clicking sounds or crepitus. Intraorally, there was no limitation in the mouth opening, and the soft tissues appeared clinically healthy. Her oral hygiene appeared fair (oral hygiene index score-1.49) [Figure 1].
Figure 1: (a) Clinical picture showing carious maxillary teeth (b) carious anterior maxillary teeth (c and d) carious and missing mandibular molars

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Decayed, missing, and filled teeth index score-19

An impression and a problem list of poor plaque control – chronic marginal gingivitis, multiple carious lesions (decayed 16; missing 3), acute apical periodontitis of 4, poor dietary habits and intake of cariogenic diet, suboptimal oral hygiene measures, and reduced salivary flow due to medication were made.

Investigations done included

  • Periapical radiographs of 4 which showed carious pulpal exposure
  • Salivary flow rate (Low unstimulated flow rate ≤ 0.1 mL/min; stimulated flow rate = 0.4 mL/min)
  • Plaque control (84% using the plaque control record of O'Leary (most accumulation seen on mesial, distal, and palatal/lingual surfaces of teeth) [Figure 2]
  • Caries risk assessment (high caries risk CRA score >15 – mainly due to past caries experience, consumption of cariogenic meals, and low salivary flow rate)
  • Dietary analysis (revealed the consumption of an average of three cariogenic meals daily not limited to mealtimes, frequent snacking, and inadequate main meals).
Figure 2: (a-d) Clinical pictures displaying pattern of plaque retention on disclosing after oral hygiene procedures by the patient. Mesial, distal, palatal, and cervical regions still had plaque retention

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Treatment plan

She was referred for pulp extirpation to relieve pain and a consultation was made to her ophthalmologist to review her medication. The definitive treatment included pretreatment clinical photographs; patient motivation and counseling on caries process, the need for good oral hygiene (to brush after breakfast and last thing at night flossing and Modified Stillman's Brushing Technique taught). Scaling and polishing were done and fluoride therapy and chemical plaque control w with Plax mouthwash for 1/12 alternated with chlorhexidine mouthwash for 1/12.

Dietary counseling

Goals set were to have adequate main meals; reduce sugary foods consumption; use of sugar substitutes, for example, Steva; limit sugar intake to <3 cubes/day for 1 month; limit consumption of sugary foods to mealtimes, and to rinse with water after each meal.

To improve salivary flow, she was advised to use sugar-free chewing gum and artificial saliva in addition to frequent sipping of small quantities of water.

Secondary and tertiary preventive treatments in addition to adequate compliance with primary preventive regimen included:



A short recall appointment was made in the Preventive Dentistry Clinic for 1 month, and the patient was required to present with recommendations by her ophthalmologist. Informed written consent was also obtained from the patient for publication of the case.


  Discussion Top


CRA involves the use of a multifactorial modeling to determine the risk factors and risk indicators or extraneous influences implicated in the complex etiology of the disease in individual patients so that interventions can be tailored, else traditional treatment regimen will fail. A number of lifestyle, environmental, and hereditary factors have been implicated in the development of dental caries. These include the frequent intake of refined carbohydrates, poor oral hygiene, high counts of cariogenic microorganisms, the inadequate use of fluoride, and impaired salivary function.[7] Diet has a local effect on oral health, primarily on the integrity of the teeth, pH, and composition of the saliva and plaque. Nutrition, however, also has a systemic effect on the integrity of the oral cavity, including the teeth, periodontium, oral mucosa, and alveolar bone.[8] Intake of sugars and other fermentable carbohydrates, which are metabolized to acids by plaque bacteria leads to a low pH and favors the growth of the acidogenic and aciduric bacteria such as mutans streptococci.[8]

Many modifying factors have also been recognized in the caries process, resulting in a more complex model that includes saliva, the immune system, time, socioeconomic status, level of education, lifestyle behaviors, and the use of fluorides.[8] Saliva is a complex mixture of water, electrolytes, and organic micromolecules and macromolecules.[9] Its secretion is regulated by reflexes involving the autonomic nervous system,[9] and it is vital to daily functioning and general well-being.[10],[11] Xerostomia affects 10%–30% of the general population,[10] and it can significantly diminish patients' quality of life.[11] The most frequent cause of hyposalivation is the use of some medications such as psycholeptics, anticoagulants, urinary antispasmodics, antidepressants, antihypertensives, antiretrovirals, hypoglycemics, levothyroxine, multivitamins, nonsteroidal anti-inflammatory drugs, and some medication used in the treatment of glaucoma.[6] The association between xerostomia and the use of some xerogenic medication has been well documented in literature, but the association between xerogenic medication like those used in the treatment of glaucoma and caries risk has not been well reported.

Primary congenital glaucoma that this patient presented with is characterized by epiphora, photophobia, and blepharospasm; secondary to the corneal epithelial edema caused by elevated intraocular pressure. The elevated intraocular pressure also causes buphthalmos, mainly at the corneoscleral junction. Patients with congenital glaucoma may undergo surgery and require follow-up examinations and medication use for life.[12] These medications, such as the one used by our patient include brimodin which is an α2-adrenoceptor agonist used to reduce ocular hypertension and to prevent further eye damage. It reduces the formation of aqueous humor and increases its drainage from the eye. It, however, causes some side effects such as dry eyes, photophobia, dizziness, headache, altered taste, and dry mouth. Xalacom is a combination product containing two different medications-latanoprost (a prostaglandin analog) which reduces ocular pressure by increasing fluid flow from the eye; and timolol which is a beta-adrenergic blocker. Its side effects are similar to that of brimodin, including dry mouth. Dorzolamide is, however, a carbonic anhydrase inhibitor that reduces the formation of aqueous humor. Apart from bitter taste in the mouth which can be reduced by occluding the nasolacrimal duct when instilling it into the eye; it has no other oral effect.

A diagnosis of hyposalivation is made when the stimulated salivary flow rate is 0.5–0.7 ml/min and the unstimulated salivary flow rate is #0.1 ml/min.[13] Salivary enhancement therapies such as local or topical agents such as artificial salivas, oral rinses and gels, flavored mouthwashes, and systemic agents such as pilocarpine HCl have been used in the treatment of xerostomia. Adequate management of xerostomia, in addition, to other modification identified risk factors through plaque control and dietary modifications is thus imperative to arrest the carious process and to prevent the development of new lesions.


  Conclusion Top


The role of medication including those used in the treatment of glaucoma in the development of xerostomia and possibly dental caries must be recognized. Patients that present to any dental clinic with multiple carious lesions must be reviewed by preventive dentistry specialists and have their caries risk assessed. It is also imperative that ophthalmologists include a dental consultation in the overall management of their patients, especially when they prescribe medication that has known oral side effects.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Keyes PH. Recent advances in caries research. Bacteriology. Int Dent J 1962;12:443-64.  Back to cited text no. 1
    
2.
Reich E, Lussi A, Newbrun E. Caries-risk assessment. Int Dent J 1999;49:15-26.  Back to cited text no. 2
    
3.
Mandel ID. The role of saliva in maintaining oral homeostasis. J Am Dent Assoc 1989;119:298-304.  Back to cited text no. 3
    
4.
de Almeida Pdel V, Grégio AM, Machado MA, de Lima AA, Azevedo LR. Saliva composition and functions: A comprehensive review. J Contemp Dent Pract 2008;9:72-80.  Back to cited text no. 4
    
5.
Fox PC, van der Ven PF, Sonies BC, Weiffenbach JM, Baum BJ. Xerostomia: Evaluation of a symptom with increasing significance. J Am Dent Assoc 1985;110:519-25.  Back to cited text no. 5
    
6.
Smidt D, Torpet LA, Nauntofte B, Heegaard KM, Pedersen AM. Associations between labial and whole salivary flow rates, systemic diseases and medications in a sample of older people. Community Dent Oral Epidemiol 2010;38:422-35.  Back to cited text no. 6
    
7.
US Department of Health and Human Services. US Public Health Service. Oral Health in America: A Report of the Surgeon General. Rockville, MD: National Institutes of Health; 2000.  Back to cited text no. 7
    
8.
Touger-Decker R, van Loveren C. Sugars and dental caries. Am J Clin Nutr 2003;78:881S-92S.  Back to cited text no. 8
    
9.
Benn AM, Thomson WM. Saliva: An overview. N Z Dent J 2014;110:92-6.  Back to cited text no. 9
    
10.
Liu B, Dion MR, Jurasic MM, Gibson G, Jones JA. Xerostomia and salivary hypofunction in vulnerable elders: Prevalence and etiology. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2012;114:52-60.  Back to cited text no. 10
    
11.
Thomson WM. Dry mouth and older people. Aust Dent J 2015;60 Suppl 1:54-63.  Back to cited text no. 11
    
12.
Dickens CJ, Hoskins HD Jr. Diagnosis and treatment of congenital glaucoma. In: Ritch R, Shields MB, Krupin T, editors. The Glaucomas. 2nd ed. St. Louis: Mosby; 1996. p. 739-49.  Back to cited text no. 12
    
13.
Sreebny LM, Vissink A, editors. Dry Mouth: The Malevolent Symptom: A Clinical Guide. Ames: Wiley-Blackwell; 2010.  Back to cited text no. 13
    


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