Medications weigh-in on tooth movement

Abstract

I know some orthodontists who also have a degree in pharmacology. I have always suspected that most of them first graduated with the intent of becoming pharmacists and then, wanting more, went back to school for a degree in dentistry and eventually specialized in orthodontics. As it turns out, their additional knowledge of prescription drugs is becoming quite an asset with the dramatic increase in medications taken by many Americans. According to a recent New York Times article, the number of medications prescribed per capita has doubled since 1995.1Harris G. British balance gain against the cost of the latest drugs. New York Times. December 2, 2008;Health section:1.Google Scholar This burgeoning of prescription and over-the-counter drug use brings to mind the importance of a review article in last month's Journal, “Medication effects on the rate of orthodontic tooth movement: A systematic literature review.”2Bartzela T. Turp J.C. Motschall E. Maltha J.C. Medication effects on the rate of orthodontic tooth movement A systematic literature review.Am J Orthod Dentofacial Orthop. 2009; 135: 16-26Abstract Full Text Full Text PDF PubMed Scopus (127) Google Scholar The authors are a highly skilled team of researchers from Nijmegen, The Netherlands, Basel, Switzerland, and Freiburg, Germany.According to these authors, most articles on this topic are related to general bone physiology in terms of density, mineralization, turnover rate, and osteoclast differentiation. However, clinical side effects, including gingival hyperplasia, xerostomia, and external root resorption, can be induced by medications. According to an orthodontist-pharmacologist who reviewed this article, “Most reviews have not reported the effects of medications on the rate of orthodontic tooth movement itself. As a result, this systematic review focused mainly on tooth movement, based primarily on well-controlled animal studies.”If you take the challenge to read this entire article, you might find it lengthy and fairly detailed, but the discussion and concluding thoughts are worth remembering. Although animal studies prevail in number, the effects of the various medications point in the same direction for the experimental animals as the few clinical studies mentioned. The most prescribed classes of medication—antidepressants, antiulcerants, cholesterol reducers, and broad-spectrum antibiotics—might be involved in orthodontically unwanted side-effects, but they appear to have no effect on the rate of orthodontic tooth movement. Therefore, the authors focused on other classes of medications, such as anti-inflammatory and antiasthmatic medications, antiarthritics, analgesics, corticosteroids, estrogens, other hormones, and calcium regulators, all of which might affect the rate of orthodontic tooth movement. Some of these groups stimulate the rate of orthodontic tooth movement, whereas others have an inhibitory effect.We know that the long-term effect of estrogen is to decrease orthodontic tooth movement. Premarin, used for menopausal symptoms or osteoporosis, was extremely common from 1960s to the 1990s, when studies showed an increase in breast cancer, stroke, and possible cardiac issues. A newer treatment for osteoporosis, raloxifene, will probably be in the same category as estrogen for decreased orthodontic tooth movement. The same could be true for chronic use of NSAIDs, which have been around for decades. Bisphosphonates belong in a much different group than any other drug listed in this review when comparing pharmacology and adverse effects. This is the only one that accumulates in the bone and has an extremely long half-life of up to 12 years (not several hours or a day like NSAIDS, raloxifene, or estrogens). It is also the only drug that has been linked with severely adverse dental and surgical effects—not only tooth movement, but also bone healing and the end stage pathology of necrosis. The American Association of Orthodontists' web site now has 75 PubMed abstracts of the best bisphosphonate articles in dentistry and has been attracting more than 100 viewers a month. And later this year, we'll publish an article by James J. Zahrowski entitled “Optimizing orthodontic treatment for patients taking bisphosphonates for osteoporosis.”Orthodontists are increasingly confronted with patients who use medications regularly, especially as more practices focus on treating patients of all ages. “In addition,” noted the authors of this systematic review, “medications are also more often prescribed to children and adolescents these days. The average American receives more than 10 prescriptions a year.” This increase is supposedly caused by 3 factors: the number of first-time users has increased, more current users take their medications for longer periods of time, and more people take more than 1 medication at the same time. The authors' advice to the clinician should get your attention: “orthodontists should assume that many patients are taking prescription or over-the-counter medications regularly. The orthodontist must identify these patients by carefully questioning them about their medication history and their consumption of food supplements.” The take-home message: “We recommend that such an inquiry should be part of every orthodontic diagnosis.” I know some orthodontists who also have a degree in pharmacology. I have always suspected that most of them first graduated with the intent of becoming pharmacists and then, wanting more, went back to school for a degree in dentistry and eventually specialized in orthodontics. As it turns out, their additional knowledge of prescription drugs is becoming quite an asset with the dramatic increase in medications taken by many Americans. According to a recent New York Times article, the number of medications prescribed per capita has doubled since 1995.1Harris G. British balance gain against the cost of the latest drugs. New York Times. December 2, 2008;Health section:1.Google Scholar This burgeoning of prescription and over-the-counter drug use brings to mind the importance of a review article in last month's Journal, “Medication effects on the rate of orthodontic tooth movement: A systematic literature review.”2Bartzela T. Turp J.C. Motschall E. Maltha J.C. Medication effects on the rate of orthodontic tooth movement A systematic literature review.Am J Orthod Dentofacial Orthop. 2009; 135: 16-26Abstract Full Text Full Text PDF PubMed Scopus (127) Google Scholar The authors are a highly skilled team of researchers from Nijmegen, The Netherlands, Basel, Switzerland, and Freiburg, Germany. According to these authors, most articles on this topic are related to general bone physiology in terms of density, mineralization, turnover rate, and osteoclast differentiation. However, clinical side effects, including gingival hyperplasia, xerostomia, and external root resorption, can be induced by medications. According to an orthodontist-pharmacologist who reviewed this article, “Most reviews have not reported the effects of medications on the rate of orthodontic tooth movement itself. As a result, this systematic review focused mainly on tooth movement, based primarily on well-controlled animal studies.” If you take the challenge to read this entire article, you might find it lengthy and fairly detailed, but the discussion and concluding thoughts are worth remembering. Although animal studies prevail in number, the effects of the various medications point in the same direction for the experimental animals as the few clinical studies mentioned. The most prescribed classes of medication—antidepressants, antiulcerants, cholesterol reducers, and broad-spectrum antibiotics—might be involved in orthodontically unwanted side-effects, but they appear to have no effect on the rate of orthodontic tooth movement. Therefore, the authors focused on other classes of medications, such as anti-inflammatory and antiasthmatic medications, antiarthritics, analgesics, corticosteroids, estrogens, other hormones, and calcium regulators, all of which might affect the rate of orthodontic tooth movement. Some of these groups stimulate the rate of orthodontic tooth movement, whereas others have an inhibitory effect. We know that the long-term effect of estrogen is to decrease orthodontic tooth movement. Premarin, used for menopausal symptoms or osteoporosis, was extremely common from 1960s to the 1990s, when studies showed an increase in breast cancer, stroke, and possible cardiac issues. A newer treatment for osteoporosis, raloxifene, will probably be in the same category as estrogen for decreased orthodontic tooth movement. The same could be true for chronic use of NSAIDs, which have been around for decades. Bisphosphonates belong in a much different group than any other drug listed in this review when comparing pharmacology and adverse effects. This is the only one that accumulates in the bone and has an extremely long half-life of up to 12 years (not several hours or a day like NSAIDS, raloxifene, or estrogens). It is also the only drug that has been linked with severely adverse dental and surgical effects—not only tooth movement, but also bone healing and the end stage pathology of necrosis. The American Association of Orthodontists' web site now has 75 PubMed abstracts of the best bisphosphonate articles in dentistry and has been attracting more than 100 viewers a month. And later this year, we'll publish an article by James J. Zahrowski entitled “Optimizing orthodontic treatment for patients taking bisphosphonates for osteoporosis.” Orthodontists are increasingly confronted with patients who use medications regularly, especially as more practices focus on treating patients of all ages. “In addition,” noted the authors of this systematic review, “medications are also more often prescribed to children and adolescents these days. The average American receives more than 10 prescriptions a year.” This increase is supposedly caused by 3 factors: the number of first-time users has increased, more current users take their medications for longer periods of time, and more people take more than 1 medication at the same time. The authors' advice to the clinician should get your attention: “orthodontists should assume that many patients are taking prescription or over-the-counter medications regularly. The orthodontist must identify these patients by carefully questioning them about their medication history and their consumption of food supplements.” The take-home message: “We recommend that such an inquiry should be part of every orthodontic diagnosis.”