VERIFIABLE CPD PAPER

RESEARCH

Systemic medicines taken by adult special care

dental patients and implications for the management
of their care
Nicholas Ransford,*1 Ben Marnell,2 Christine Randall,3 Clare Yates4 and Gillian Howie5

Key points
Highlights the importance of the medication list
in assessing a patient’s medical history.
Provides an overview of the most commonly taken Covers the implications for dental care and
medicines that clinicians are likely to come across in summarises the clinical tools available to manage
adults including those accessing specialist special them.
care dentistry.

Abstract
Introduction Significant changes have taken place in the profile of prescription medicines being taken by the adult UK
population over the last decade. The aims of this article are to review the literature to understand the overall trends
and underlying factors, and then to compare this with the medication profile of a cohort of adult special care dental
(SCD) patients.
Materials and method Five hundred patient records were examined and retrospective data on systemic medicines
being taken were obtained and classified according to the index used in the British National Formulary (BNF).
Results The results revealed a high level of polypharmacy with 57% of SCD patients taking three or more medicines
compared to 24% of the population in England. Antiepileptic drugs were the most frequently taken group of
medicines (42%), followed by antidepressants (39.7%) and antipsychotics (37.6%).
Conclusions Our results demonstrate the medical complexity of patients in this cohort and enable clinicians to increase
their familiarity with the most commonly taken medicines and the tools available to manage the implications for
dental care.

Introduction
Significant changes have taken place in the
use of prescription medicines by the UK adult
population in recent years and yet there is little
current published information on the relevant
1
Consultant in Special Care Dentistry, Birmingham Dental
Hospital, 5 Mill Pool Way, Pebble Mill, Birmingham,
B5 7SW, UK; 2Dental Core Trainee, Birmingham Dental
Hospital, 5 Mill Pool Way, Pebble Mill, Birmingham, B5
7SW, UK; 3Assistant Director and Lead Pharmacist for
Dental Medicines Information and Pharmacovigilance,
North West Medicines Information Centre, 70 Pembroke
Place, Liverpool, L69 3GF, UK; 4Specialist in Special Care
Dentistry, Birmingham Dental Hospital, 5 Mill Pool Way,
Pebble Mill, Birmingham, B5 7SW, UK; 5Speciality Trainee in
Special Care Dentistry, Birmingham Dental Hospital, 5 Mill
Pool Way, Pebble Mill, Birmingham, B5 7SW, UK.
*Correspondence to: Nicholas Ransford
Email address: nicholas.ransford@nhs.net
Refereed Paper.
Accepted 11 November 2020
https://doi.org/10.1038/s41415-021-3180-z
issues for dentistry. This paper revisits this topic
a decade on from a previous service review
of a cohort of special care dentistry (SCD)
patients1 and looks at the context in terms of
the national changes in prescribing for adults.
This is a useful subgroup to study because,
under national policy,2 patients with a severe
disabling, medical or mental health condition
are referred to the SCD speciality and are more
likely to be taking prescribed medication than
other dental patients. However, as higher
levels of medication use have also been found
in patients using hospital dental services3 and
public sector services in other countries,4,5
an up-to-date knowledge of pharmacology is
essential for all dental clinicians. Recognition
of medicines on a patient’s medication list helps
to identify diagnosed medical conditions, gives
an indication of their severity and control, and
flags up important dental care and prescribing
issues that may need to be managed.
This article will review the changes in
primary care prescribing for adults in
England over the last decade before going on
to describe the method and results from a new
service review carried out on a cohort of SCD
patients. The implications for clinical practice
are covered in the discussion, focusing on the
most common problems. The British National
Formulary (BNF) should be consulted for a full
list of side effects and drug interactions.
Changes in prescribing at national
level
Information on prescribing in the NHS in
England is available online from NHS Digital.6
Examination of this data shows a 46.8% overall
increase in prescriptions dispensed in primary
care from 2006  to 2016 (752 million to 1.1
billion). An 8.4% population growth over this
period accounts for some of the increase,7 but

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the number of items dispensed per person

Table 1 The ‘top 20’ prescribed BNF sections in England in the community in 2018 and the
per year also increased by 35.4% from 14.8 to change since 200874
20.0,8 with 24% of all adults taking three or
BNF 2008 2018
more medicines. Polypharmacy is associated BNF section name
chapter (millions) (millions)
% change
with ageing and 9% of those aged 45–55 years
Lipid-regulating drugs 02 52.1 74.3 42.3
are taking five or more medicines, rising to
56% of those aged 85 or over. Polypharmacy Hypertension and heart failure 02 57.8 72.1 24.7
is also associated with social deprivation,
Antidepressant drugs 04 36.0 70.9 97.1
multimorbidity, long-term health conditions,
mental health problems and high body mass Gastric antisecretory drugs + mucosal protectants 01 36.1 66.1 83.2
index (BMI), as well as changes in medical Analgesics 04 54.5 63.1 15.8
practice including preventive prescribing.9,10
Drugs used in diabetes 06 32,6 55.0 68.8
Care home residents are particularly likely to be
taking multiple medications; one study found Nitrates, calcium channel blockers and other
02 39.1 50.2 28.4
anti-anginal drugs
that residents of average age of 85 years were
taking an average of eight medicines each.11 Beta-adrenoceptor blocking drugs 02 27.6 38.6 39.7
Optimisation of drug prescribing is a new Antibacterial drugs 05 38.9 35.6 -8.4
NHS England initiative involving pharmacists
Antiplatelet drugs 02 38.1 34.1 -10.5
carrying out targeted medication reviews for
patients at high risk of polypharmacy-related Thyroid and anti-thyroid drugs 06 20.9 32.9 57.2
adverse effects.12
Diuretics 02 37.5 32.4 -13.8
Tables 1  and 2 summarise the main
prescribing trends over the last decade by BNF Vitamins 09 13.2 31.2 136.2
class and medication name. The overall themes Bronchodilators 03 26.0 31.0 19.0
are the major efforts to prevent cardiovascular
Anti-epileptic drugs 04 11.6 28.1 141.6
disease and gastro-intestinal (GI) bleeding,
and the spiralling use of antidepressants Drugs used in rheumatic diseases and gout 10 23.2 22.2 -4.0
and analgesics. Notable increases have also Corticosteroids (respiratory) 03 15.9 20.9 31.7
occurred with antidiabetic and anti-epileptic
medicines. The reasons for these changes will Drugs for genito-urinary disorders 07 8.8 19.9 126.1
now be covered under those four main clinical Anaemias + other blood disorders 09 10.0 19.5 94.0
systems which account for the majority of
Laxatives 01 14.49 18.5 28.4
prescribing.

Cardiovascular system depression, socioeconomic factors, ageing,15 Recently, antidepressants, opioids,

The large increase in the use of statins –
especially atorvastatin, antihypertensives such
as ramipril, losartan, amlodipine, bisoprolol
and the antiplatelet drug clopidogrel – is
due to the national drive to prevent stroke
and cardiovascular disease under National
Institute for Health and Care Excellence
(NICE) guidelines and the Quality and
Outcomes Framework in general medical
practice from 2004.13 The overall reduction in
the antiplatelet figure in Table 1 is due to a fall
in aspirin prescribing due to the risk of GI or
extracranial bleeding.14
Central nervous system
The reasons for the steep rise in the prescribing
of antidepressants, particularly sertraline and
other selective 5-hydroxytryptamine reuptake
inhibitors, are not fully clear but have been
attributed to an increased prevalence of
better recognition of mental health issues
among patients and professionals, and increases
in long-term therapy.16 Among older people,
10.7% of over-65s are on antidepressants,
rising to 29.2% for care home residents.17 This
is partly explained by the rise in dementia
where antidepressants and memantine are
used to manage the condition in place of
antipsychotics because of the associated risk of
stroke, somnolence, extrapyramidal symptoms
and accelerated cognitive decline.18
Regarding analgesics, the main increase has
been in opioid prescriptions, where a 34% rise
over a ten-year period has been reported mostly
for chronic non-cancer pain, while the use of
non-opioid analgesics has diminished. The
main increases were buprenorphine used for the
treatment of opioid dependence, oral morphine,
oxycodone, fentanyl, codeine phosphate and
tramadol.19 Additionally, a threefold increase
in prescription of gabapentinoids between
2007–2017 has been reported.20
gabapentinoids, benzodiazepines and the
Z-drugs (zopiclone, zolpidem) have been the
subject of a Public Health England review over
concerns about dependence, risks and the lack
of evidence of benefits.21 Also, the NICE have
a new draft guideline out for consultation.22
Now taken by one in four of the population,
these medicines have higher use in women,
older people and the socially deprived. The
British Medical Association have linked this
to an increased prevalence of mental health
problems, poor access to mental health
services, increased demand for GP services
and the ageing population.23
Over the 2008–2018 period, anti-epileptic
drugs (AEDs) recorded a 142% increase due
to the increased prevalence of epilepsy and
its management by multi-drug therapy, with
a quarter of all patients with epilepsy taking
more than one AED.24 This is also partly due
to the BNF classification of gabapentinoids
under the AED section, although prescribed

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aripiprazole. Corresponding reductions have

Table 2 The ‘top 30’ prescribed medicines in England in the community in 2018 and the
change since 200874 occurred in the older ‘typical’ group including
promazine, chlorpromazine and haloperidol
BNF medicinal name BNF 2008 2018 % change
chapter (millions) (millions) due to side effects including rigidity, tremor,
drowsiness and tardive dyskinesia, although
Atorvastatin 02 10.7 42.0 290.4
current guidelines do support their use for
Levothyroxine sodium 06 20.4 32.2 57.6 some patients with schizophrenia.28 In people
Omeprazole 01 15.6 31.0 98.5
with learning disability without a diagnosis
of mental illness, there has been a reduction
Amlodipine 02 15.0 29.1 94.2 in antipsychotic use in line with national
Ramipril 02 17.4 28.6 64.2 initiatives to reduce their use in managing
challenging behaviour,29 although a quarter
Lansoprazole 01 13.9 25.5 83.4
still take antipsychotics for this reason.30
Simvastatin 02 33.9 24.3 -28.2

Bisoprolol fumarate 02 6.8 23.6 247.1 Respiratory system

Colecalciferol 09 8.1 23.6 189.7
Changes in the types of drugs prescribed for
Aspirin 02 32.7 23.4 -28.4 respiratory conditions have been relatively
Metformin hydrochloride 06 11.6 21.8 87.8 minor, although an overall increase in
prescriptions has occurred. Those with the
Salbutamol 03 17.9 21.6 20.6
largest increase are the newer preparations with
Paracetamol 04 17.4 18.5 6.4 a move towards double- or triple-combination
Co-codamol (codeine phosphate/paracetamol) 04 14.2 15.2 7.1 therapies and away from monotherapies,
including long-acting muscarinic antagonists
Sertraline hydrochloride 04 2.1 14.8 596.0
such as tiotropium and long-acting beta
Citalopram hydrobromide 04 8.9 14.1 58.2 agonists such as salmeterol and inhaled
corticosteroids. There have also been
Amitriptyline hydrochloride 04 7.2 13.5 87.7
increases in prescriptions for oral drugs such
Furosemide 02 11.3 11.9 5.8 as montelukast used as add-on therapy.31 This
Beclometasone dipropionate 03 6.3 10.7 69.1 has been consistent with changes in guidance
for management of chronic obstructive
Influenza vaccine 14 9.6 10.3 7.5
pulmonary disease 32,33 and asthma.34
Bendroflumethiazide 02 19.2 10.0 -48.0

Amoxicillin 05 13.3 9.9 -25.6 Endocrine system

Losartan potassium 02 3.2 9.8 204.7
An increase in the prescribing of antidiabetic
Clopidogrel 02 3.6 9.8 170.3 drugs is due to the rise in obesity-induced type
Mirtazapine 04 2.4 8.9 266.7 II diabetes. Metformin is still the preferred
first-line drug, with increasing use of newer
Lisinopril 02 9.2 8.9 -4.0
agents as second-line – ie DPP-4 inhibitors
Warfarin sodium 02 7.7 8.2 6.7 (eg sitagliptin)  +  SGLT2 inhibitors (eg
dapagliflozin).35,36
Folic acid 09 3.1 8.0 158.0
Increases in the prescribing of
Gabapentin 04 1.8 7.4 319.3 levothyroxine for the nonspecific symptoms
Tamsulosin hydrochloride 07 2.6 7.2 180.2 of hypothyroidism have been found to be of
little benefit,37 have been linked to an increased
risk of osteoporosis in older women38 and are
for other purposes such as neuropathic pain, carbamazepine, phenobarbitone and sodium the subject of NICE guidance.39
generalised anxiety disorder and migraine. valproate in women of child-bearing age
The profile of AED prescribing has seen a due to evidence of associated congenital Other notable changes
switch to newer drugs including levetiracetam, malformations.26,27
lamotrigine, zonisamide and lacosamide, due Although not shown in Table 1, it is The large increase in prescription of proton
to their better safety and tolerance record.25 interesting that there has been an overall pump inhibitors (PPIs) (eg omeprazole)
Use of the benzodiazepines clobazam and 34.9% increase in prescribing of antipsychotics is likely to be due to their effectiveness in
clonazepam for refractory epilepsy has also between 2008  and 2018 mainly accounted treating gastro-oesophageal reflux and peptic
increased by 92.7% and 87.4%, respectively. for by the ‘atypical group’, which includes ulcer disease, and their prophylactic use in
Reductions have occurred for phenytoin, quetiapine, risperidone, olanzapine and preventing the bleeding risk associated with

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long-term use of aspirin or non-steroidal An 8.4% reduction in antibiotic prescribing Service review method
anti-inflammatory drugs (NSAIDs). However, has come about in response to national policy
recent concerns have been raised about to manage antimicrobial resistance.45 However, We obtained retrospective data for a cohort of
inappropriate prescribing of PPIs and, while considerable variation remains between SCD patients by retrieving electronic records
not incontrovertible,40 there is evidence of geographical areas with higher prescribing in for the first consecutive 500 patients aged
adverse reactions including malabsorption, practices with older or more deprived patient 16  years or over attending the Birmingham
Clostridium difficile infections, fractures41,42 bases. Out-of-hours services, both medical and Community Healthcare SCD service in April
and lower GI enteropathy.43 The NICE have dental, have been found to have a higher rate 2019. Exclusions were those seen solely because
issued guidance to rationalise the use of PPIs.44 of prescribing of antibiotics.46,47 of dental anxiety or where a medical history
had not been completed. Data was captured
Fig. 1 The most frequently occurring conditions (note that conditions may coexist and are using an anonymised SmartSurvey database
not mutually exclusive) tool. No attempt was made to standardise
the way clinicians had recorded or defined
Parkinson’s 1% conditions; some conditions were not mutually
Kidney disease 1% exclusive and may have coexisted in the same
Multiple sclerosis 2% patient, and no triangulation took place with
Oncology 3% GP or hospital records. As the aim was to
COPD 3% produce purely descriptive data, no attempt
Hypertension 4% was made to match subjects, control variables
Hypothyroid 4% or carry out statistical analyses.
Stroke/TIA 5% Data on medication was classified according
Cerebral palsy 5% to the system used in the BNF, excluding those
Dementia 6% of minor relevance to dental practice. Therefore,
Other mental health 6% topically applied creams and ointments,
Down syndrome 6% vitamins and diet supplements, laxatives,
Depression 6% antibiotics, over-the-counter analgesics,
Schizophrenia 8% hormone replacement therapy, contraceptives
Rheumatological 8% and hay fever remedies were excluded.
Cardiac 9% The project was registered and approved
Asthma 9% by the Birmingham Community Healthcare
Diabetes type 2 9% Trust Dental Divisional Audit Committee to
Autism 16% be undertaken as a service review.
Epilepsy 23%
Learning disability 40% Results
0% 10% 20% 30% 40% 50%
The total number of records included was
% of patients with condition (n=500) 500. The mean age was 46, with 25.4% of patients
aged over 60 and 10.6% aged over 75. In total,
54% had a learning disability, 29% a physical
Fig. 2 Number of medications taken by patients disability, 23% a mental health condition and
23% a severe medical condition. Figure 1 shows
18%
17% a breakdown of the main conditions listed in
16%
16% patients’ medical histories.
14% The number of medications taken by
14%
12%
individual patients is shown in Figure
12%
2. Overall, 86% of patients were taking
10%
Patients (%)

10%
9%
medication, 57% were taking three or more
8%
and 40% were taking four or more medicines.
7%
The highest number of recorded medicines
6%
5% taken by any single patient was 17.
4%
4%
3% Figure 3 shows that AEDs were the most
2% frequent group of medicines taken by 42%
2%
of patients, followed by antidepressants and
0%
0 1 2 3 4 5 6 7 8 9 10+
antipsychotics (39.4% and 37.6%, respectively).
Number of medicines per patient
The most frequently taken medicines are
shown in Figure 4 and a detailed list arranged
by BNF classification is shown in Appendix 1.

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Medicines used when conditions are difficult

Fig. 3 The most frequently taken medications by BNF section
to control are shown in Appendix 2.

Urinary frequency/retension 2.8%

Antispasmodics
Discussion
4.2%

Neuromuscular disorders 4.4% The data

Anticoagulants 5.0% This service review was undertaken for clinical
Inhaled corticosteroid 5.4% educational purposes and, as such, the design
Calcium channel blockers 8.6% suited its purpose. As the data is descriptive
Beta-blockers 9.0%
and from a convenience cohort, the results
cannot be generalised to other services or
Antiplatelet drugs 9.2%
compared directly to other cohorts.
Beta2-agonist 10.0%
Nevertheless, the number of medicines
Thyroid drugs 10.2%
taken per person is broadly similar to the
Diurectics 10.2%
2009 cohort and any apparent increase could
Lipid lowering therapy 10.8% be due to the exclusion of patients with dental
Drugs used in diabetes 14.4% anxiety in the 2019 cohort. Here, 57% were
Anti-Parkinson’s 19.2% taking three or more medicines compared to
Hypertension and heartfailure 20.2% 24% in the population of England. Those most
Hypnotics, anxiolytics and analgesics 21.8% frequently taken, shown in Figures 3 and 4, are
consistent with the profile of conditions listed
Disorders of gastric acid and ulceration 27.6%
for SCD patients in Figure 1. When compared
Antipsychotic drugs 37.6%
to the top 20 medicines prescribed in general
Antidepressants 39.4%
medical practice,48 the profile for SCD patients
Anti-epileptics 42.0% shown in Table 3 is similar but skewed towards
0.0 10.0 20.0 30.0 40.0 50.0 AEDs, antidepressants and antipsychotics.
% of patients taking medicine (n=500)
Clinical implications
Oral health
Fig. 4 Most commonly taken medications The changes in Tables 1  and 2 represent
an increased risk of medication-induced
Furosemide 5.4% xerostomia and subsequent dental caries
Levetiracetam 5.6% related to antihypertensives, antidepressants,
Pregabalalin 5.6%
antipsychotics, opioids, gabapentinoids and
Amlodipine
anti-epileptics.49 This is particularly significant
5.6%
for SCD patients as people with severe disability,
Aspirin 5.8%
medical or mental health conditions often
Lamotrigine 6.0%
take a combination of these medicines, which
Diazepam 6.0% multiplies the risk.50 Difficulties with accessing
Ramipril 6.2% services can result in caries presenting at a late
Metformin 7.6% stage and becoming extensive. An appropriate
Lorazepam 7.8% prevention regime needs to be put in place with
Sertraline 7.8% care teams as well as prescription of remedies
Procyclidine for dry mouth.49,51
8.0%
Omeprazole
Drug-induced gingival overgrowth is a well-
8.6%
known side effect of some AEDs and calcium
Carbamazepine 9.6%
channel blockers.52 While mainly associated
Salbutamol 9.8%
with phenytoin, this problem can occur with
Simvastatin 9.8% some of the newer AEDs (eg zonisamide,
Levothyroxine 10.2% levetiracetam, topiramate, valproic acid,
Sodium valproate 14.6% clobazam) and is more likely in patients on
Risperidone 14.6% multi-drug therapy.53 It has also been reported
Lansoprazole 14.8%
in patients taking amlodipine, nifedipine,
felodipine and verapamil, but because the
0.0 2.0 4.0 6.0 8.0 10.0 12.0 14.0 16.0
published research predates the widespread
% of patients taking medicine (n=500) use of these drugs, the true association remains
unknown.52 While effective plaque control is the

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first line of treatment, this can be impossible

Table 3 Top 20 SCD BNF groups compared to general practice48
to achieve with some patients, and if surgery
is carried out to remove excess gingival tissue, Drug, class or BNF grouping SCD rank SCD (%) GP rank GP (%)
relapse may occur. Possible options for drug Anti-epileptic drugs 1 52 16 1.9
substitution should be explored at an early
Antipsychotic drugs 2 37.6 94 0.1
stage with the neurologist, particularly for
patients with refractory epilepsy taking multiple Ulcer-healing drugs 3 27.6 2 5.5
AEDs. However, for some individuals, periodic SSRIs 4 19.4 6 3.2
gingivectomy remains the only option.54
Hypnotics and anxiolytics 5 19.2 32 1
Other less common but important soft tissue
implications are oral ulceration associated with Lipid regulators 6 18.6 1 6.5
beta blockers and nicorandil,55 angioedema Anti-Parkinson’s 7 13 58 0.4
with angiotensin-converting enzyme (ACE)
Oral antidiabetic drugs 8 11 15 1.9
inhibitors56 and oral fungal infections with
steroid inhalers.57 ACE inhibitors 9 10.2 3 4.3

Diuretics 10 10.2 7 3.1

Medical risk assessment
The usefulness of a patient’s medication list
as part of the risk assessment of perioperative
adverse medical events has previously been
described.1 Identification of medical conditions
and their severity will be aided by familiarity
with the list in Appendix 1 showing the most
commonly taken medicines. Caution is needed
in the clinic to identify generic medicine names
when trade names are listed because important
medicines may otherwise be missed; for
example, isosorbide mononitrate, for which
the BNF lists 13 different trade names. The
medicines listed in Appendix 2 indicate a severe,
unstable or difficult-to-control condition and
should prompt further assessment and liaison
with any medical specialists involved.
Bleeding risk
The management of perioperative bleeding
risk in dental patients taking antiplatelet or
anticoagulant drugs is covered by Scottish
Dental Clinical Effectiveness Programme
(SDCEP) guidelines.58 Use of the newer direct
oral anticoagulants (DOACs) rivaroxaban and
apixaban is increasing rapidly while warfarin
is declining. This may be due to the extent of
warfarin’s interaction with other drugs to cause
bleeding, as well as the cost and inconvenience
for warfarinised patients in having to have
their international normalised ratio regularly
monitored. This is not a requirement with
DOACs. The ten-year figure quoted in Table
2 masks a steady decline in the use of warfarin
since 2013.
Healing risk
The 21.7% increase in alendronic acid
prescriptions and other bisphosphonates,
RANKL inhibitors and anti-angiogenic drugs
(eg denusomab, sunitinib) represents a risk of
Thyroid and anti-thyroid drugs 11 10.2 8 2.9
Beta-2 agonists 12 10 10 2.3
Antiplatelet drugs 13 9 34 0.9
Beta blockers 14 9 5 3.6
Calcium channel blockers 15 8.6 4 3.7
Other antidepressants 16 7 30 1
Urinary frequency/retention 17 5.8 44 0.6
Inhaled corticosteroids 18 5.4 14 2
Oral anticoagulants 19 5 69 0.3
Tricyclic antidepressants 20 5 19 1.6
medication-related osteonecrosis of the jaw. Risk significance of these interactions has not been
identification and mitigation has been widely quantified and, in practice, the mandatory
covered in dental literature and guidelines.59 requirements of titration, monitoring of vital
signs and availability of flumazenil during a
Local anaesthesia and intravenous sedation procedure enable any such effects to be
conscious sedation mitigated.64
While there are reports of a theoretical potential Long-term opioid users are often difficult
for local anaesthetics containing adrenaline to to sedate and may require large doses of
trigger hypertensive episodes in patients taking midazolam.65 This has also been reported with
beta blockers and arrhythmias in those taking benzodiazepine users due to drug tolerance66
tricyclic antidepressants or anti-arrhythmics, and includes patients taking lorazepam for
a recent evidence review concluded that at challenging behaviour or clonazepam or
doses used in dentistry, these are not clinically clobazam for refractory epilepsy.67
significant and serious interactions are
exceedingly rare.60 In patients with significant Dental prescribing and adverse drug
cardiovascular disease, it has been recommended interactions
to administer local anaesthetic with caution and This topic is also covered by SDCEP guidelines68
to monitor their vital signs.61,62 and several groups of medicines highlighted
Possible interactions have also been reported in this study interact with drugs listed in the
between midazolam used for conscious sedation Dental Practitioners’ Formulary to cause adverse
and a range of medicines highlighted in this reactions. Of these, the most common is GI
study, including antidepressants, antipsychotics bleeding and this is most likely to occur with
(notably clozapine),63 calcium channel blockers, use of NSAIDs69 in patients who are older,70 or
as well as azole antifungals and macrolide taking anticoagulants,71 antiplatelets, selective
antibiotics. Again, while this could result in serotonin reuptake inhibitors (SSRIs) or aspirin.
over-sedation or prolonged recovery, the clinical Also, the long-term use of NSAIDs can reduce

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the effectiveness of antihypertensives including
calcium channel blockers, beta blockers and
ACE inhibitors, whereas macrolide antibiotics
can reduce blood pressure further when
combined with some antihypertensives. While
current evidence supports the use of NSAIDs
or an NSAID/paracetamol combination as the
optimal choice for dental analgesia,72 patients at
risk of GI bleeding should be asked about any
recent episodes of GI bleeding or anaemia, and
whether they are taking a PPI. Co-codamol is
a useful alternative and is available in 8/500 or
12.8/500 formulations without a prescription. If
an NSAID cannot be avoided, the GP should be
contacted to consider short-term co-prescribing
of omeprazole or lansoprazole for those not
already taking a PPI.73 This is particularly the case
with diclofenac, which is of higher potency and
higher bleeding risk than ibuprofen.
Conclusions
This study has described the medication profile
of a cohort of adult SCD patients, half of which
comprised people with a learning disability,
as being characterised by polypharmacy,
AEDs, antidepressants, antipsychotics and in
some cases significant medical complexity.
The national picture for all adults is one of
significantly increased prescribing across most
medicine groups, notably antidepressants,
opioid analgesics and PPIs. National guidelines
have played an increasingly important role
in shaping prescribing practice, as evidence
has emerged of the questionable risk/benefit
profile of some medicines.
It is therefore more important than ever for
dental clinicians to be aware of the medication
their patients are taking, the implications for
care and the relevant guidelines. Familiarity
with the most commonly taken medicines listed
in Tables 1 and 2 and in Appendix 1 will help to
flag up any increased risk of oral disease, adverse
perioperative medical events or post-operative
complications that may need to be managed.
Conflict of interest
The authors declare no conflicts of interest.
Acknowledgements
The authors would like to thank Dr Rupert Ransford,
Consultant Gastroenterologist and British Society of
Gastroenterology Clinical Guidelines Lead; Dr Alex
Crighton, Consultant/Honorary Senior Lecturer in
Oral Medicine; Dr Nick Walker, Occupational Health
Physician; Anne-Marie Rawlins for data capture; and
Heather Lewis for the presentation of Appendix 1.
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Appendix 1 Full list of medications taken listed by BNF section and subsection (numbers in brackets indicate the number of patients
taking this drug) (Cont. on page 41)
BNF section Drug type Common example Number of % of patients
patients taking taking

1 Gastro-intestinal system

1.1 Chronic bowel disorders Mesalazine (8) 8 1.6

1.3 Acute diarrhoea Loperamide (1) 1 0.2

1.6 Antispasmodics Hyoscine (10), mebeverine (4), pirenzepine (4), tetrabenazine (2) 21 4.2

1.4.1 Dyspepsia Gaviscon (3) 3 0.6

1.4.2 Ulcer-healing drugs Lansoprazole (74), omeprazole (43), ranitidine (13), pirenzepine (4) 138 27.6

2 Cardiovascular system

2.1 Positive inotropes Digoxin (5) 5 1

2.1 Anti-arrhythmics Amiodarone (2), sotalol (1) 3 0.6

2.1 Peripheral vasodilators Naftidrofuryl* 0 0

2.3.2 Oral anticoagulants Warfarin (9), rivaroxaban (8), apixaban (7), dabigatran (1) 25 5

2.3.2 Antiplatelet drugs Aspirin (29), clopidogrel (16) 45 9

2.4.1 Beta blockers Propranolol (21), bisprolol (19), atenolol (5) 45 9

2.4.1 Vasodilator antihypertensive Minoxidil* 0 0

2.4.1 Centrally acting antihypertensives Moxonidine (1) 1 0.2

2.4.1 Calcium channel blockers Amlodipine (28), felodipine (11), nifedipine (2) diltiazem (1) 43 8.6

2.4.1 ACE inhibitors Ramipril (31), lisinopril (8), perindopril (11), enalapril (1) 51 10.2

2.4.1 Angiotensin II receptor antagonists Losartan (7), candesartan (4), valsartan (2) 13 2.6

2.6 Lipid regulators Simvastatin (49), atorvastatin (39), rosuvastatin (3), pravastatin (2) 93 18.6

2.7 Antithrombotics Ticagrelor (1) 1 0.2

2.7 Nitrates Isosorbide (6), glyceryl trinitrate (5) 11 2.2

2.7 Other anti-anginal drugs Nicorandil (1), ivabradine (1) 2 0.4

2.8 Diuretics Furosemide (27), sprinolactone (10), bendroflumethiazide (8), indapamide (2) 51 10.2

3 Respiratory system

3.1 Bronchodilators Tiotropium (4), ipratropium bromide (3) 7 1.4

3.1 Beta 2 agonists Salbutamol (49), formoterol (1) 50 10

3.1 Inhaled corticosteroids Beclometasone (15), budesonide (5), futicasone (5), Fostair (2) 27 5.4

4 Nervous system

4.1 Drugs for dementia Donazepil (4), memantine (3), rivastigmine (1), rivastigmine (1), galantamine (1) 9 1.8

4.5 Nausea and vertigo Metoclopramide (4), betahistine (2), domperidone (1), prochlorperazine (1) 8 1.6

4.6 Opioid analgesics Tramadol (8), oramorph (6), buprenorphine (2), fentanyl (1) 19 3.8

4.8 Substance dependence Methadone (2) 2 0.4

4.3.1 Hypnotics and anxiolytics Lorazepam (39), diazepam (30), zoplicone (23), temazepam (2) 96 19.2

4.3.2 CNS stimulants Methylphenidate (3), lisdexamfetamine (1) 4 0.8

4.3.3 Antimanic drugs Lithium (4), atomoxetine (3), valproic acid (1) 8 1.6

4.3.3 Anti-epileptics Sodium valproate (73), lamotrigine (30), pregabalin (28), levetiracetam (28) 260 52

4.3.4 Tricyclic antidepressants Amitriptyline (20), dosulepin (3), lofepramine (1), clomipramine (1) 25 5

4.3.4 SSRIs Sertraline (39), fluoxetine (26), citalopram (24), paroxetine (5) 97 19.4

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Appendix 1 Full list of medications taken listed by BNF section and subsection (numbers in brackets indicate the number of patients
taking this drug) (Cont. from page 41)
BNF section Drug type Common example Number of % of patients
patients taking taking

4.3.4 Other antidepressants Mirtazepine (22), duloxetine (7), venlafaxine (6) 35 7

4.3.6 Antipsychotic drugs Risperidone (73), aripiprazole (16), clozapine (14), quetiapine (13) 173 34.6

4.3.6 Antipsychotic depot injections Zuclopenthixol (13), promethazine (11), flupenthixol (2), paliperidone (2) 15 3

4.4.2 Anti-parkinsonian Procyclidine (40), rotigotine (3), selegiline (2), levodopa (2) 56 11.2

4.6.1 Headache Sumatriptan (1) 1 0.2

5 Infection

5.6.4 Antiretrovirals Abacavir with dolutegravir and lamivudine (1) 1 0.2

6 Endocrine system

6.3.1 Insulins Insulin (17) 17 3.4

6.3.1 Oral antidiabetic drugs Metformin (38), glicazide (9), sitagliptin (3), linagliptin (2) 55 11

6.9 Thyroid and antithyroid drugs Levothyroxine (51) 51 10.2

6.2 Corticosteroids Prednisolone (7), hydrocortisone (2), dexamethasone (1), fludrocortisone (1) 13 2.6

6.4 Bisphosphonates Alendronic acid (10), zolendronic acid (1) 12 2.4

7 Genito-urinary system

7.1 Urinary frequency/retention Solifenacin (6), doxazosin (6), tamsulosin (7), tolterodine (3) 29 5.8

8 Immune system and malignant disease

8.1 Immunosuppressants Azathioprine (1), tacrolimus (1) 2 0.4

8.3 Cytotoxics Methotrexate (5), hydroxycarbamide (2) 7 1.4

10 Musculoskeletal system

10.2 Gout Allopurinol (7) 7 1.4

10.3 Neuromuscular disorders Baclofen (16) quinine (4), dantrolene (1), tizanidine (1) 22 4.4

10.4 NSAIDs Diclofenac (6), naproxen (1) 7 1.4

Key:
* = denotes drug did not feature in the audit but given as an example for illustrative purposes.

Appendix 2 Oral medicines indicating patient’s condition is severe or difficult to control

System Condition Medicine

Ischaemic heart disease/acute coronary syndrome Nicorandil, ivabradine, ranolazine, prasugrel, ticagrelor

Cardiac Arrhythmia Amiodarone, flecainide, mexilitine

Heart failure Eplenerone

Cardiovascular system Hypertension Moxonidine, hydralazine, minoxidil

Central nervous system Epilepsy Clobazam, clonazepam

Respiratory Asthma Oral prednisolone, montelukast, ipratropium nebuliser

Endocrine Diabetes Dulaglutide, exenatide

Mental health Agitation Haloperidol, olanzapine

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