Patient Counseling

Patient Counseling

Children Underprotected by Dental Sealants - NIDR nly 7.6% of American schoolchildren have cavity-preventing dental sealants on their teeth, according to a survey by the federal government's National Institute of Dental Research. The findings were reported at the recent annual meetingofthe American Association for Dental Research in San Francisco. The survey of almost 40,000 schoolchildren, aged 5 to 17, was conducted during the 1986-87 school year at schools throughout the country. The dentists recorded a number of oral conditions, including sealant usage and tooth decay. The sample population was selected to represent the approximately 43 million schoolchildren in the coun-

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try.

'By combining the use of sealants and fluorides, tooth delay could be virtually eliminated.'

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Dental sealants, which are thin plastic films painted on the chewing surfaces of molars and premolars (the teeth directly in front of molars), have been continually improved since they became available commercially in the early 1970s. According to Dr. Preston A. Littleton, Jr., deputy director of the Institute and deputy chief dental officer of the U.S. Public Health Service, the chewing surfaces of children's teeth are the most susceptible to decay and the least benefited by fluorides. The survey found that two-thirds of all cavities now occur in this vulnerable area of the tooth, where the pits and fissures trap food particles and bacteria, which eventually fuel the decay process. "By combining the use of sealants and fluorides, tooth decay could be virtually eliminated," Littleton added. Sealants, which can be transparent or color tinted, are painted onto molars much the same way that

nail polish is applied to fingernails. Because sealants prevent decay by the physical barrier they create rather than by a chemical reaction, the decay protection is determined by the sealant's ability to adhere to the tooth. As long as the sealant

remains intact, decay will not develop beneath it. Sealants generally can last as long as 10 years. Not only do sealants protect healthy teeth, but research has shown that they arrest decay when placed on top of a cavity early in development by sealing off the supply of nutrients to the cavity. "This is a totally pain-free, preventative measure that is extremely effective," Littleton said. According to the American Dental Association's most recent data (1985), the cost of applying a sealant to one tooth is approximately $10 to $15. A growing number of insurance companies have begun to reim.:. burse for applying sealants, making it more affordable. ®

Focus on Hearing Loss Caused by Drugs: Better Hearing and Speech Month harmacists are urged to pay speP cial attention to those medications that can produce hearing loss and balance disturbances during May, this year's Better Hearing and Speech Month. Medications that cause such loss include aminoglycoside antibiotics, other antibiotics, and loop diuretics. Many of the most common medications, including aspirin, can cause physiological changes in the ear, which has been largely ignored by health-care professionals. Some medications are more toxic than others: • All aminoglycoside antibiotics are ototoxic and nephrotoxic. Streptomycin is considered more toxic to the vestibular system than to the cochlea, but the converse is so for neomycin and kanamycin. Their toxicity appears to affect both vestibular and cochlear structures. • Vancomycin, a parenteral penicillin substitute for severe gram-positive coccal infections, is potentially ototoxic and nephrotoxic, especially if recommended doses are exceeded or if excretion is delayed by diminished renal function. Mild and transient minocycline-induced vertigo also may occur.

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• There are no indications for the use of kanamycin that outweigh its disadvantages of cochlear toxicity, nephrotoxicity, and ineffectiveness against pseudomonas organisms. • Neomycin is the most cochlear toxic of all drugs, consequently it is recommended only for topical use. Even topical therapy has resulted in hearing loss when large areas were treated, allowing high systemic absorption. • Gentamicin (Garamycin), tobramycin (Nebcin), and amikacin (Amikan) are aminoglycosides most useful in current clinical practice. Netilmicin may produce less ototoxicity than other aminoglycosides. • Polymyxins, including polymyxin B (Aerosporin) and polymyxin E (colistin and colistimethate or ColyMycin). Ototoxicity from their use in ototopical preparations is a theoretical rather than a practical problem, and parenteral therapy is no longer a common practice. • Viomycin is a rather toxic substitute for streptomycin in treatment of tuberculosis. It is not in common usage. • Aminoglycosides are excreted almost entirely by the kidneys. Therefore, impaired renal function pro17

Patient Counseling

longs the excretion time and results in high tissue concentrations that enhapce the risk of ototoxicity. Serum creatinine levels should be monitored before and during therapy. Some sources recommend that in patients with impaired renal function, the maintenance dose of an aminoglycoside is approximately half of the normal dose, and it is given at intervals approximately four times the numerical value of the serum creatinine (in mg/100 mI). Besides impaired renal function, other factors that increase the risk of ototoxicity include prolonged treatment course (more than 10

days), concomitant use ofloop diuretics such as ethacrynic acid or furosemide (Lasix), concomitant use of other nephrotoxic or ototoxic drugs, advanced age, previous aminoglycoside therapy, and neural-type hearing loss. To reduce risks, physicians should avoid prescribing ototoxic medications unless absolutely necessary, minimize the length of time on the drugs, monitor the patient's hearing during treatment, and look at the workers' medical histories when hearing loss is identified. Patients whose serum levels exceed the recommended levels or

Arthritis Education Materials Available

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o support National Arthritis Month, the Arthritis Foundation has assembled a special kit of materials for pharmacists to use in educating the public on the disease and its treatment. Included in the pharmacist packet is a sample letter for pharmacists to send to their local newspaper editors. It is intended to show the community the pharmacist's concern for arthritis patients and to portray the pharmacist as a resource for helpful advice. Also included in the packet are two resource lists: a basic listing of

brochures suitable for both lay and professional audiences available from the Arthritis Foundation, and a listing of materials intended for health professionals. All materials may be ordered from local Arthritis Foundation chapters. One of the news items reported is the discovery of a genetic reason that not all persons infected by Lyme-disease-carrying ticks contract rheumatoid arthritis. One study showed that persons with HLA-DR3 or DR4 genes were more likely to develop chronic arthritis. Because Lyme disease can be con-

Nutrition Guidelines for AIDS patients

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he first comprehensive practical nutrition guidelines for AIDS patients have been issued by the National Task Force on Nutrition. They are designed to provide specific, appropriate direction for all health-care professionals involved in the treatment of AIDS. Nutrition is one of the most troublesome problems facing those who work with AIDS patients. Many of the wide variety of symptoms associated with AIDS - from mouth sores and pain to anorexia, nausea and vomiting - make good nutrition difficult. Although more than 90% of those involved in the care of patients agree that nutrition

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is important, only 20% of the institutions have a standard nutrition protocol for AIDS patients. The complete guidelines appear in the January/February issue of Nutrition: An International Journal of Applied and Basic Nutritional Science. Among those recommendations: • Nutritional support should be given before the individual becomes malnourished to protect against nutritional complications. • 94% of AIDS patients in one ,study developed oral infection, which may interfere with eating. For individuals who have difficulty chewing or swallowing because of

those who develop nephrotoxicity or symptoms of ototoxicity should be tested, and the drug dosages should be adjusted. Although ototoxicity may be irreversible and may progress after cessation of therapy, in some patients discontinuation of the drug results in some increment of improvement. J. Philip Keeve, director of Occupational Health Services for the Pentagon, stressed the increasing importance of educating healthcare providers and the public about ototoxicity because it is unlikely that use of medication will decrease.®

trolled, it has become a model for other research on what happens in rheumatoid arthritis. Other drug-research news include summaries of studies and approval of methotrexate, information on a new cortisone steroid still under research, and research on cyclosporin in the treatment of rheumatoid arthritis. One item summarizes a study of risk factors in rheumatoid-arthritis patients. Materials should be requested from local chapters of the Arthritis Foundation. The national office's address is Arthritis Foundation, 1314 Spring Street, Atlanta, GA 30309. (404) 872-7100. ® painful mouth sores, simple changes in the texture, temperature, and consistency of foods may improve the ability to eat. • If the digestive tract works, use it. The gastrointestinal tract is the preferred route of feeding to maintain its structure and function. • Elemental enteral diet formulas that contain less than 5% fat often are indicated to relieve the symptoms of diarrhea, a common and often severe consequence of AIDS. Such formulas replace the critical nutrients lost because of diarrhea or malabsorption. • Fluids should be encouraged between meals. Drug therapy, infection, or malignancy can cause lengthy bouts of nausea and vomiting, leading to weight loss, electro-

American Phannacy, Vol. NS29, No.5 May 1989/326

Patient Counseling lyte imbalances, and dehydration. Good fluid choices are broth, water, ginger ale, and clear fruit juice, such as apple juice. Greasy, highfat, spicy foods should be avoided. Dry cereal, crackers, and toast can be offered to relieve nausea. • Total Parenteral Nutrition (TPN) increases risk of catheter-related infection, and should be used only with a totally nonfunctional gastrointestinal tract. Myron Winick, MD, professor of nutrition at Columbia University

and chairman of the task force, said, "To date, the lack of clinical research on nutrition and AIDS has impeded efforts to provide the most appropriate nutritional care for these individuals. We believe these guidelines offer positive direction to health professionals. "Sound nutritional status can significantly improve the overall quality of life and well-being for the person with AIDS. More importantly, early, aggressive nutritional intervention in malnourished patients

New Guidelines for Hypertension Care Published

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ew guidelines, published in the 1988 Report of the Joint National Committee on Detection, Evaluation, and Treatment ofHigh Blood Pressure, allow greater flexibility for the clinician and greater involvement by the patient in treating hypertension. The goal - to maintain blood pressure below 140/90 mm Hg - remains unchanged. The new guidelines recommend: • Expansion of initial drug therapy to include calcium antagonists and angio-tensin-converting enzyme (ACE) inhibitors, with the previously recommended diuretics and beta-blockers. About half of the patients with mild hypertension can be treated with one of four types of drugs. • Lower initial dosages of antihypertensive medications. If the blood pressure is not reduced to 1401 90 mmHg or lower, the dosages can be increased. The committee also recommended the use of combination therapy (which employs small doses of drugs that have different mechanisms of action) to allow adequate blood-pressure control with potentially fewer dose-dependent side effects. Some patients can safely be placed on lower medication dosages (step-down therapy). With proper nonpharmacologic management and close follow-up, some patients can be withdrawn from drug therapy entirely. • Revision of recommendations on alcohol consumption. Patients

with high blood pressure should limit themselves to two drinks a day - 2 oz. of 100-proof whiskey, 8 oz. of wine, or 24 oz. of beer. The systematic, effective management of hypertension has a

may help improve symptoms, reduce infection, and enhance response to drug therapy." The guidelines are being distributed to physicians, dieticians, and other care givers involved in the management of those with AIDS. A consumer pamphlet is also being disseminated throughout the AIDS community by national and local AIDS organizations. Copies of the guidelines can be obtained from Wang Associates, Inc., 19 W. 21st St., New York, NY 10010. @

great potential for reducing mortality for the large numbers of people with high blood pressure, including the millions with "mild" hypertension (see Am Pharm, NS28, 440, July 1988). A study conducted in 1988 by the National Heart, Lung, and Blood Institute showed that after 5 years of treatment, patients receiving stepped care lived as much as 8.3 years longer. ®

Table 1. Stepped Care for Hypertension: Revised Guidelines Step 1 For appropriate patients, begin with nonpharmacologic approaches. These nonpharmacologic approaches include sodium and alcohol restriction, weight control, tobacco avoidance, exercise, modification of dietary .fats.

Step 2 Begin drug therapy with a diuretic, beta-blocker, calcium antagonist, or ACE inhibitor.

Step 3 Add a second drug of different class (options include diuretics, beta-blockers, calcium antagonists, ACE inhibitors, alpha 1-blockers, centrally acting alpha 2-adrenergic agonists, rauwolfia serpentina, vasodilators). or Increase the dosage of the first drug. or Substitute another drug.

Step 4 Add a third drug of a different class. or Substitute a second drug.

Step 5 Gonsider ft.Jrthe(, ev~luation or referral.

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~~r of control, considJi ";decreasing or

Joint National

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