- Email: [email protected]
DEALING WITH DISASTERS
L E T T E R S
LETTERS
Totowa, NJ: Humana; 2004:9. 5. Flanagan D. Understanding the grapefruit-drug interaction. Gen Dent 2005;53:282-5.
ADA welcomes letters from readers on articles and other information that has appeared in The Journal. The Journal reserves the right to edit all communications and requires that all letters be signed. Letters must be no more than 550 words and must cite no more than five references. No illustrations will be accepted. Readers may submit their letters by e-mail to “[email protected]”, by fax to 1-312-440-3538 or by mail to 211 E. Chicago Ave., Chicago, Ill. 60611-2678. The views expressed are those of the letter writer and do not necessarily reflect the opinion or official policy of the Association. Brevity is appreciated.
Author’s response: We appreciate Dr. Flanagan calling attention to a potentially important interaction between some orally administered medications and grapefruit juice. While outside the scope of the workshop reported on in our JADA article, practitioners who administer drugs that interact with grapefruit juice should be cognizant of the potential for more pronounced effects from inhibition of drug metabolism by the hepatic cytochrome pathway. The potential for a clinically relevant interaction between orally administered triazolam and grapefruit juice is described by Dr. Flanagan1 and may be more pronounced for sublingual administration. He recommends that dental patients who will be sedated with oral medications such as midazolam, triazolam and diazepam should avoid grapefruit for at least two days before sedation. Previous reports have demonstrated that sublingually administered triazolam results in greater peak plasma levels than does orally administered triazolam,2,3 resulting in greater central nervous system (CNS) effects from the drug. A study in healthy volunteers reported a 1.5-fold increase in mean triazolam levels in the circulation, delayed the time to peak time of triazolam from 1.6 to 2.5 hours and increased CNS effects of a 0.25 milligram dose administered with grapefruit juice.4 Given the potential for even greater levels of sedation for triazolam when administered sublingually to patients who have recently ingested grapefruit juice, less predictable
J
ORAL SEDATION
I read with great interest the excellent article on oral sedation by Dr. Raymond Dionne and colleagues in March JADA.1 However, the authors do not discuss the important interaction of orally-administered triazolam and other benzodiazepines with grapefruit and other citrus products.2-5 Dr. David Bailey and his colleagues have shown that this wellestablished interaction may increase these drugs’, clinical bioavailability and risk of toxicity. Dennis Flanagan, DDS Willimantic, Conn. 1. Dionne RA, Yagiela JA, Coté CJ et al. Balancing efficacy and safety in the use of oral sedation in dental outpatients. JADA 2006;137:502-13. 2. Bailey DG, Dresser GK. Natural products and adverse drug interactions. Can Med Assoc J 2004;170:1531-2. 3. Flanagan D. Oral triazolam sedation in implant dentistry. J Oral Implantol 2004; 30:93-7. 4. Bailey DG. Grapefruit juice-drug interaction issues. In: Boullata JI, Armenti VT, eds. Handbook of drug-nutrient interactions.
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JADA, Vol. 137
time to peak blood levels and enhanced CNS depression, dentists should avoid elective oral or sublingual sedation with a benzodiazepine in patients who have recently consumed grapefruit juice. Raymond A. Dionne, DDS, PhD Scientific Director National Institute of Nursing Research National Institutes of Health Bethesda, Md. 1. Flanagan D. Understanding the grapefruit-drug interaction. Gen Dent 2005;53:282-5. 2. Berthold CW, Dionne RA, Corey SE. Comparison of sublingually and orally administered triazolam for premedication before oral surgery. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;84:119-24. 3. Kroboth PD, McAuley JW, Kroboth FJ, Bertz RJ, Smith RB. Triazolam phamacokinetics after intravenous, oral and sublingual administration. J Clin Psychopharmacol 1995;15:259-62. 4. Hukkinen SK, Varhe A, Olkkola KT, Neuvonen PJ. Plasma concentrations of triazolam is increased by concomitant ingestion of grapefruit juice. Clin Pharmacol Ther 1995; 58:127-31.
DEALING WITH DISASTERS
April JADA had several upbeat articles about the role of dentists in coping with natural and man-made catastrophic disasters.1-3 There is no question that the manpower required in the health care arena to mount a significant response to an overwhelming event makes the inclusion of dentists essential. Dentists are well-versed in the subject of infection and antibiotic administration, and they are well-trained and deft in injecting medications. Patient management is certainly one of their strong assets. Sadly, though the U.S. Department of Homeland Security may entertain these grandiose plans for dental participation in an emergency, the reality is quite different. I recently attended a point-of-
http://jada.ada.org July 2006 Copyright ©2006 American Dental Association. All rights reserved.
L E T T E R S
distribution training session at which there was a simulated bioterrorist anthrax attack. Much to my surprise and chagrin, dentists were told that only physicians, physician assistants, nurse practitioners and nurses could deal with medical issues and manage the triage tables. Obviously, such weighty issues as asking a patient if he was allergic to ciprofloxacin or doxycycline were beyond the capacity of the dentist, who was relegated to crowd control. I am delighted that the Illinois legislature has passed a law to modify the scope of dental practice during an emergency, allowing dental participation. Unfortunately, New York remains in the dark ages on this issue. My opinion on this is borne out by remarks from Isaac Weisfuse, MD, MPH, deputy commissioner, Division of Disease Control, Department of Health and Mental Hygiene, the City of New York. In a March 10, 2006, letter to the New York County Dental Society, Dr. Weisfuse stated that “per the New York State Education Department Office of the Professions, only medical doctors can evaluate potential contraindications to antibiotics or vaccines. Other professionals who are licensed to work in collaboration with or under the direct supervision of a medical doctor (nurse practitioners, physician assistants, registered nurses) could also evaluate patients for potential contraindications.” This seems to suggest, outrageous as it seems, that in our practices we are illegally prescribing antibiotics if a physician is not supervising. Instead of dentists spending
time and energy in training for the Medical Reserve Corps at this time, they should devote their efforts to educating their state representatives to the true nature of a dental education, and how dentists can be better utilized in disasters. Charles S. Solomon, DDS New York City 1. Rinaggio J, Glick M. The smallpox vaccine: an update for oral health care professionals. JADA 2006;137:452-60. 2. Katz AR, Nekorchuk DM, Holck PS, Hendrickson LA, Imrie AA, Effler PV. Dentists' preparedness for responding to bioterrorism: a survey of Hawaii dentists. JADA 2006;137:461-7. 3. Colvard MD, Lampiris LN, Cordell GA et al. The dental emergency responder: expanding the scope of dental practice. JADA 2006;137:468-73.
Authors’ response: We deeply appreciate Dr. Solomon’s comments, sentiments and observations. Dr. Solomon accurately notes that many local directors and managers of the nation’s various disaster and emergency medicine response agencies do not appreciate the significant contribution the oral health care profession can make to infrastructure, personnel and a timely response during a disaster event. With annual changes in seasonal weather and the constant threat of a man-made disaster, it would seem that disaster managers would want to take advantage of, tap into and empower the oral health profession and its resources to provide for a robust triage and pandemic surge, recovery and reconstitution effort, when needed. Illinois is fortunate to have forward-thinking visionaries in senior state-level positions who, without doubt, saw and defined a robust role for the oral health care profession in disaster medicine. Hesitation was present, not because of skill sets, but rather because of
long-standing legal definitions of scopes of practice. The critical leap occurred, however, when Illinois political and public health leaders perceived that dentists do perform emergency medicine. These same leaders then perceived that definitions of scope of practice were not eternally fixed as unchangeable statements and were modifiable. The Illinois State Dental Society (ISDS) through consistent and constant political will, advocated the need to change state law. ISDS gathered support from leadership within our colleague medical professions and built political support within the Illinois legislature. Clearly, our experience reveals that the oral health profession needs to, and must constantly, justify what it can bring to the disaster medicine community. Dentistry today has a respected public perception. However, when have we, as a profession, projected to the public that we can contribute more health care than just treating caries and whitening teeth? This is the new reality. If we cannot justify why, we will not be invited to the table. The majority of the individual health care providers who we encountered at the boots-to-theground level, and regardless of training, “get it.” These health care providers showed, almost universally, acceptance, not resistance. Policy and planning leaders, however, have a different mission. They respond to political needs and the will of the people. They need and seek justifications, through public law, that can satisfy legal oversight. Our experience suggests that
JADA, Vol. 137 http://jada.ada.org Copyright ©2006 American Dental Association. All rights reserved.
July 2006
945
LETTERS
Totowa, NJ: Humana; 2004:9. 5. Flanagan D. Understanding the grapefruit-drug interaction. Gen Dent 2005;53:282-5.
ADA welcomes letters from readers on articles and other information that has appeared in The Journal. The Journal reserves the right to edit all communications and requires that all letters be signed. Letters must be no more than 550 words and must cite no more than five references. No illustrations will be accepted. Readers may submit their letters by e-mail to “[email protected]”, by fax to 1-312-440-3538 or by mail to 211 E. Chicago Ave., Chicago, Ill. 60611-2678. The views expressed are those of the letter writer and do not necessarily reflect the opinion or official policy of the Association. Brevity is appreciated.
Author’s response: We appreciate Dr. Flanagan calling attention to a potentially important interaction between some orally administered medications and grapefruit juice. While outside the scope of the workshop reported on in our JADA article, practitioners who administer drugs that interact with grapefruit juice should be cognizant of the potential for more pronounced effects from inhibition of drug metabolism by the hepatic cytochrome pathway. The potential for a clinically relevant interaction between orally administered triazolam and grapefruit juice is described by Dr. Flanagan1 and may be more pronounced for sublingual administration. He recommends that dental patients who will be sedated with oral medications such as midazolam, triazolam and diazepam should avoid grapefruit for at least two days before sedation. Previous reports have demonstrated that sublingually administered triazolam results in greater peak plasma levels than does orally administered triazolam,2,3 resulting in greater central nervous system (CNS) effects from the drug. A study in healthy volunteers reported a 1.5-fold increase in mean triazolam levels in the circulation, delayed the time to peak time of triazolam from 1.6 to 2.5 hours and increased CNS effects of a 0.25 milligram dose administered with grapefruit juice.4 Given the potential for even greater levels of sedation for triazolam when administered sublingually to patients who have recently ingested grapefruit juice, less predictable
J
ORAL SEDATION
I read with great interest the excellent article on oral sedation by Dr. Raymond Dionne and colleagues in March JADA.1 However, the authors do not discuss the important interaction of orally-administered triazolam and other benzodiazepines with grapefruit and other citrus products.2-5 Dr. David Bailey and his colleagues have shown that this wellestablished interaction may increase these drugs’, clinical bioavailability and risk of toxicity. Dennis Flanagan, DDS Willimantic, Conn. 1. Dionne RA, Yagiela JA, Coté CJ et al. Balancing efficacy and safety in the use of oral sedation in dental outpatients. JADA 2006;137:502-13. 2. Bailey DG, Dresser GK. Natural products and adverse drug interactions. Can Med Assoc J 2004;170:1531-2. 3. Flanagan D. Oral triazolam sedation in implant dentistry. J Oral Implantol 2004; 30:93-7. 4. Bailey DG. Grapefruit juice-drug interaction issues. In: Boullata JI, Armenti VT, eds. Handbook of drug-nutrient interactions.
944
JADA, Vol. 137
time to peak blood levels and enhanced CNS depression, dentists should avoid elective oral or sublingual sedation with a benzodiazepine in patients who have recently consumed grapefruit juice. Raymond A. Dionne, DDS, PhD Scientific Director National Institute of Nursing Research National Institutes of Health Bethesda, Md. 1. Flanagan D. Understanding the grapefruit-drug interaction. Gen Dent 2005;53:282-5. 2. Berthold CW, Dionne RA, Corey SE. Comparison of sublingually and orally administered triazolam for premedication before oral surgery. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;84:119-24. 3. Kroboth PD, McAuley JW, Kroboth FJ, Bertz RJ, Smith RB. Triazolam phamacokinetics after intravenous, oral and sublingual administration. J Clin Psychopharmacol 1995;15:259-62. 4. Hukkinen SK, Varhe A, Olkkola KT, Neuvonen PJ. Plasma concentrations of triazolam is increased by concomitant ingestion of grapefruit juice. Clin Pharmacol Ther 1995; 58:127-31.
DEALING WITH DISASTERS
April JADA had several upbeat articles about the role of dentists in coping with natural and man-made catastrophic disasters.1-3 There is no question that the manpower required in the health care arena to mount a significant response to an overwhelming event makes the inclusion of dentists essential. Dentists are well-versed in the subject of infection and antibiotic administration, and they are well-trained and deft in injecting medications. Patient management is certainly one of their strong assets. Sadly, though the U.S. Department of Homeland Security may entertain these grandiose plans for dental participation in an emergency, the reality is quite different. I recently attended a point-of-
http://jada.ada.org July 2006 Copyright ©2006 American Dental Association. All rights reserved.
L E T T E R S
distribution training session at which there was a simulated bioterrorist anthrax attack. Much to my surprise and chagrin, dentists were told that only physicians, physician assistants, nurse practitioners and nurses could deal with medical issues and manage the triage tables. Obviously, such weighty issues as asking a patient if he was allergic to ciprofloxacin or doxycycline were beyond the capacity of the dentist, who was relegated to crowd control. I am delighted that the Illinois legislature has passed a law to modify the scope of dental practice during an emergency, allowing dental participation. Unfortunately, New York remains in the dark ages on this issue. My opinion on this is borne out by remarks from Isaac Weisfuse, MD, MPH, deputy commissioner, Division of Disease Control, Department of Health and Mental Hygiene, the City of New York. In a March 10, 2006, letter to the New York County Dental Society, Dr. Weisfuse stated that “per the New York State Education Department Office of the Professions, only medical doctors can evaluate potential contraindications to antibiotics or vaccines. Other professionals who are licensed to work in collaboration with or under the direct supervision of a medical doctor (nurse practitioners, physician assistants, registered nurses) could also evaluate patients for potential contraindications.” This seems to suggest, outrageous as it seems, that in our practices we are illegally prescribing antibiotics if a physician is not supervising. Instead of dentists spending
time and energy in training for the Medical Reserve Corps at this time, they should devote their efforts to educating their state representatives to the true nature of a dental education, and how dentists can be better utilized in disasters. Charles S. Solomon, DDS New York City 1. Rinaggio J, Glick M. The smallpox vaccine: an update for oral health care professionals. JADA 2006;137:452-60. 2. Katz AR, Nekorchuk DM, Holck PS, Hendrickson LA, Imrie AA, Effler PV. Dentists' preparedness for responding to bioterrorism: a survey of Hawaii dentists. JADA 2006;137:461-7. 3. Colvard MD, Lampiris LN, Cordell GA et al. The dental emergency responder: expanding the scope of dental practice. JADA 2006;137:468-73.
Authors’ response: We deeply appreciate Dr. Solomon’s comments, sentiments and observations. Dr. Solomon accurately notes that many local directors and managers of the nation’s various disaster and emergency medicine response agencies do not appreciate the significant contribution the oral health care profession can make to infrastructure, personnel and a timely response during a disaster event. With annual changes in seasonal weather and the constant threat of a man-made disaster, it would seem that disaster managers would want to take advantage of, tap into and empower the oral health profession and its resources to provide for a robust triage and pandemic surge, recovery and reconstitution effort, when needed. Illinois is fortunate to have forward-thinking visionaries in senior state-level positions who, without doubt, saw and defined a robust role for the oral health care profession in disaster medicine. Hesitation was present, not because of skill sets, but rather because of
long-standing legal definitions of scopes of practice. The critical leap occurred, however, when Illinois political and public health leaders perceived that dentists do perform emergency medicine. These same leaders then perceived that definitions of scope of practice were not eternally fixed as unchangeable statements and were modifiable. The Illinois State Dental Society (ISDS) through consistent and constant political will, advocated the need to change state law. ISDS gathered support from leadership within our colleague medical professions and built political support within the Illinois legislature. Clearly, our experience reveals that the oral health profession needs to, and must constantly, justify what it can bring to the disaster medicine community. Dentistry today has a respected public perception. However, when have we, as a profession, projected to the public that we can contribute more health care than just treating caries and whitening teeth? This is the new reality. If we cannot justify why, we will not be invited to the table. The majority of the individual health care providers who we encountered at the boots-to-theground level, and regardless of training, “get it.” These health care providers showed, almost universally, acceptance, not resistance. Policy and planning leaders, however, have a different mission. They respond to political needs and the will of the people. They need and seek justifications, through public law, that can satisfy legal oversight. Our experience suggests that
JADA, Vol. 137 http://jada.ada.org Copyright ©2006 American Dental Association. All rights reserved.
July 2006
945