Polypharmacy in the Elderly Dental Patient

Polypharmacy in the Elderly Dental Patient – DentoLink

DentoLink · Algeria

The polymedicated geriatric patient in the dental office — identifying at-risk interactions, xerostomia as the first warning sign, and adapting prescribing to age-altered pharmacokinetics.

Clinical PharmacologyGeriatricsAGS Beers Criteria 2023Professional Use2026

Polypharmacy — generally defined as the simultaneous use of 5 or more medications — affects a growing share of elderly patients. It multiplies the risk of interactions, adverse effects, and iatrogenic events, which account for 5 to 10% of hospitalizations after age 65. The dental surgeon, both a prescriber and a privileged observer through xerostomia, has a role of vigilance to play.

Defining Polypharmacy and Its Risks

A simple definition, a major issue

The WHO defines polypharmacy as the simultaneous administration of numerous medications, or the administration of an excessive number of medications — a threshold generally set at 5 or more molecules taken at the same time. This situation affects a significant proportion of people over 65, with prevalence increasing alongside age and the number of chronic conditions.

Polypharmacy is also driven by the phenomenon of "prescribing cascades" — a medication prescribed to treat the side effect of a previous treatment, without an overall reassessment of the prescription — and by the multiplicity of prescribers, each sometimes unaware of the others' prescriptions.

A documented public health issue

Iatrogenic events account for 5 to 10% of hospitalizations in patients over 65 — a large share of which is preventable. The increase in the number of medications is directly correlated with an increase in potentially inappropriate prescriptions and the risk of drug interactions.

Age-Altered Pharmacokinetics

Physiological aging changes the way the body handles medications, independent of any associated pathology. These changes explain why a standard prescription for a young adult can be unsuitable, or even dangerous, for an elderly patient.

Reduced renal and hepatic clearance

Renal function and hepatic metabolism progressively decline with age, even in the absence of an identified pathology, prolonging the half-life of many drugs and increasing the risk of accumulation.

Changes in body composition

Decreased lean mass and relatively increased fat mass, altering the volume of distribution of lipophilic drugs — potentially prolonging their effect.

Increased sensitivity to adverse effects

Increased pharmacodynamic sensitivity for numerous classes — sedatives, anticholinergics, antihypertensives — at a plasma concentration equivalent to that of a young adult.

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The resulting practical principle

Start at the lowest possible dose, particularly for drugs with a narrow therapeutic index — an initial dose of one-third to one-half of the usual adult dose is often recommended for frail patients over 75.

Xerostomia: The First Clinical Signal of Polypharmacy

The dental surgeon's sentinel role

Drug-induced xerostomia is the first adverse effect of polypharmacy observable in the oral cavity. Its presence, particularly when it develops or progressively worsens, should alert the practitioner to possible underlying polypharmacy — and can be an opportunity for a useful dialogue with the treating physician about the appropriateness of the entire prescription.

Dry mouth affects about 30% of people aged 65 and over, and this frequency is very largely attributable to the medications consumed rather than to physiological aging itself. The most common mechanism is anticholinergic: numerous therapeutic classes interfere with the nerve receptors of the salivary glands, reducing secretion.

Xerogenic drug class	Examples	Mechanism
Antidepressants (mainly tricyclics, but also SSRIs)	Amitriptyline, paroxetine	Anticholinergic effect
Urinary anticholinergics	Oxybutynin, solifenacin (incontinence)	Direct blockade of salivary muscarinic receptors
Antiparkinsonian agents	Trihexyphenidyl	Potent anticholinergic effect
First-generation antihistamines	Hydroxyzine	Anticholinergic effect
Diuretics	Furosemide, hydrochlorothiazide	Relative general dehydration
Antihypertensives	Certain ACE inhibitors, beta-blockers	Variable mechanism, less consistent
Benzodiazepines and opioids	Various molecules	Associated central sedative effect

Cumulative effect — anticholinergic burdenIn the polymedicated patient, each medication with anticholinergic properties, even modest ones individually, adds to the others — a phenomenon sometimes quantified using a cumulative anticholinergic burden score. Xerostomia that is severe and disproportionate to a single identified medication should prompt a search for this cumulative effect across the patient's entire prescription.

Managing Xerostomia in the Office

A practical approach in-office

Measures accessible to the dental surgeon, in addition to a possible prescription review by the treating physician.

Hydration and salivary stimulation measures — drink small amounts of water regularly, sugar-free or xylitol chewing gum to stimulate residual secretion, avoid alcohol, coffee, and acidic beverages which worsen dryness.

Artificial saliva — saliva substitute gels or sprays, used particularly before meals and at bedtime, especially useful for removable denture wearers who are more exposed to dryness-related discomfort.

Reinforced dental protection — regular topical fluoride application (in-office fluoride varnish, at-home gel), increased dental check-up frequency (every 3 to 4 months rather than annually), due to the increased risk of root caries typical of chronic xerostomia.

Notify the treating physician when relevant — in cases of severe and disabling xerostomia, suggest a prescription review with the prescriber, identifying the most likely causative molecules if possible.

Specific clinical consequences to monitorChronic xerostomia favors cervical (root) caries — at the base of the tooth, on exposed root surfaces — rather than classic coronal caries, as well as oral candidiasis and discomfort under removable dentures. These atypical locations should prompt a systematic search for xerostomia in elderly patients.

At-Risk Interactions with Common Dental Prescriptions

Dental prescription	Elderly patient's concurrent treatment	Risk
NSAIDs	VKAs, DOACs, antiplatelets, ACE inhibitor + diuretic	Bleeding, acute kidney injury — see NSAID article
Amoxicillin	Methotrexate	Reduced renal clearance of methotrexate — potential toxicity
Metronidazole	VKAs	Potentiation of anticoagulant effect — see VKA article
Macrolides (azithromycin, clarithromycin)	Statins	Risk of rhabdomyolysis via inhibition of statin metabolism
Tramadol	SSRI/SNRI antidepressants	Serotonin syndrome, reduced efficacy — see opioids article
Epinephrine-containing local anesthetics	Non-selective beta-blockers	Blood pressure elevation — see vasoconstrictors article
Azole antifungals (fluconazole)	Anticoagulants, statins, benzodiazepines	Multiple interactions via CYP450 inhibition

The Beers Criteria — Drugs to Use with Caution

The Beers Criteria, published and regularly updated by the American Geriatrics Society (most recently in 2023), identify potentially inappropriate medications for older adults — a useful reference for the prescribing dental surgeon, particularly for molecules used routinely.

Anticholinergics (hydroxyzine in particular)

Sedation, confusion, worsened xerostomia

Increased risk of confusion, falls, and urinary retention in elderly patients
Preferred alternative for dental anxiolytic premedication: assess the actual benefit before routine prescribing (see conscious sedation article)

Benzodiazepines

Falls, confusion, prolonged sedation

Significantly increased risk of falls and fractures in elderly patients
Slowed elimination — prolonged residual effect compared to young adults
Particular caution for any sedative dental premedication in this patient

Long-term NSAIDs

Increased GI and renal risk

Heightened gastrointestinal and renal toxicity in elderly patients, particularly in combination with other nephrotoxic treatments
Confirms the need to limit prescription duration (see NSAID article)

Prescribing Principles in the Elderly

Practical rules for geriatric dental prescribing

Applicable to any prescription — analgesic, antibiotic, sedative — in patients over 75 or frail patients.

Start at a reduced dose — about one-third to one-half of the usual adult dose for drugs with a narrow therapeutic index, particularly in frail or very elderly patients.

Check renal function if available — a recent workup (creatinine, clearance) is valuable before prescribing any renally-cleared antibiotic or NSAID.

Favor the best-tolerated molecules — paracetamol rather than NSAIDs as first-line, amoxicillin rather than macrolides in the absence of contraindication (fewer interactions with frequently prescribed statins).

Limit prescription duration — to the strict minimum necessary, with prompt reassessment rather than routine extension.

Avoid adding a medication without reviewing the full prescription — systematically ask the patient (or caregiver) for an up-to-date list of all their treatments before any new prescription.

A Structured Medication History

Common gap

Simply asking "are you taking any medications?" — a question that is too vague, to which the elderly patient often responds incompletely, omitting treatments perceived as minor (supplements, old treatments, self-medication).

A structured approach

Explicitly ask the patient to bring their prescription or full pillbox to the consultation. Ask specifically about anticoagulants, antiplatelets, corticosteroids, psychiatric treatments, supplements, and self-medication — each category separately rather than one blanket question.

The caregiver as a resourceIn patients with cognitive impairment or significant frailty, involving the caregiver or companion in the medication history significantly improves the reliability of the information gathered — the patient alone may no longer be able to accurately report their treatment.

Coordination with Other Prescribers

The dental surgeon, as a full-fledged prescriber, participates in the medication safety chain for the polymedicated elderly patient. This responsibility includes vigilance in pharmacovigilance and coordination with other healthcare professionals involved.

The dental surgeon's role in the geriatric care pathway

Report any adverse effect suspected of being drug-related, including those prescribed by other practitioners. Inform the treating physician of any new dental prescription likely to interact with the baseline treatment. Do not hesitate to seek an opinion before an at-risk prescription in a patient whose overall prescription is not fully known.

Algerian Context

Specificities of the elderly Algerian patient population

The growing prevalence of chronic diseases (diabetes, hypertension, cardiac conditions) among the elderly Algerian population is accompanied by polypharmacy just as common as elsewhere. The frequent absence of a shared medical record between different prescribers (treating physician, cardiologist, endocrinologist, dental surgeon) makes a structured medication history all the more essential — the dental surgeon often cannot rely on a centralized record to know the patient's full treatment regimen.

Self-medication and traditional supplementsAmong elderly Algerian patients, the use of herbal supplements or traditional remedies alongside conventional drug treatment remains common and is rarely mentioned spontaneously. Some herbs have anticoagulant properties or interact with ongoing treatments — broaden the history-taking to include these practices, without judgment, to obtain a complete picture of the patient's treatment. For a detailed review of these interactions, see the article Herbal Medicine, Dietary Supplements and Self-Medication in Dentistry on the DentoLink blog.

Access to a health record and treatment list

Encourage the elderly patient or their caregiver to keep an up-to-date list of all treatments taken, in simple paper form if necessary, to be systematically presented at every medical or dental consultation — a simple practice that considerably improves the safety of care in the absence of a widespread shared digital record.

FAQ — Common Clinical Questions

Ask precisely about all treatments taken, particularly anticholinergics, antidepressants, diuretics, and antihypertensives. Drug-induced xerostomia is by far the most common cause in the polymedicated elderly patient, far more than physiological aging itself. In the absence of an identified causative treatment, consider other diagnoses (Sjögren's syndrome, dehydration) and refer if necessary.

Not systematically at the usual dosage for normal renal function, but vigilance is required. Check renal function if a recent workup is available, and adjust the dosage or dosing interval in cases of known renal impairment. For amoxicillin in particular, adjustment is necessary in cases of severe renal impairment — refer to the SmPC for precise adjustment.

With heightened caution. Check for the absence of a concurrent serotonergic antidepressant (risk of serotonin syndrome and reduced efficacy), favor a reduced initial dose, and inform the patient about the risk of sedation and falls — tramadol is among the molecules to be used with caution in the elderly according to the Beers Criteria, particularly due to the risk of confusion and falls.

Explicitly ask the patient or caregiver to bring the current prescription or pillbox to the appointment — this simple request considerably improves the reliability of the information gathered compared to a verbal history alone. In cases of persistent doubt about a treatment with interaction risk (an anticoagulant in particular), contact the treating physician directly before any significant surgical procedure.

They provide a useful reference framework for molecules common to dental practice (NSAIDs, benzodiazepines, hydroxyzine, tramadol), without being a dental-specific prescribing tool. Their main value is to raise the practitioner's awareness of the classes requiring increased caution in the elderly, complementing individual clinical judgment and knowledge of the patient.

With caution — macrolides, particularly clarithromycin, can inhibit the metabolism of certain statins and increase the risk of rhabdomyolysis. Azithromycin carries a lower interaction risk than clarithromycin via this metabolic pathway, but still warrants monitoring. When in doubt, prefer amoxicillin or clindamycin in the absence of contraindication, as they present a more favorable interaction profile with statins.

References

1. The 2023 American Geriatrics Society Beers Criteria® Update Expert Panel. American Geriatrics Society 2023 updated AGS Beers Criteria® for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2023;71(7):2052-2081. 2023

2. MSD Manuals — Professional Edition. Drug-related problems in older adults — geriatric pharmacokinetics. reference

3. Bedel C. Polypharmacy in older adults: definition, issues, and management in oral medicine. Doctoral thesis in dental surgery. Université Paris Cité. thesis

4. OMéDIT Centre-Val de Loire. Geriatrics — geriatric therapeutic handbook, iatrogenesis and falls in the elderly. 2023. 2023

5. Synapse Medicine. Addressing the challenges of drug prescribing in the elderly — French epidemiological data on polypharmacy. summary

6. Revue Médicale Suisse. Polypharmacy and the elderly. 2024. 2024

7. MSD Manuals — Professional Edition. Xerostomia — drug causes, management, caries risk. reference

8. Madinier I, et al. Drug-induced hyposalivation. Ann Med Interne. 1997. historical reference

9. Cumulative Anticholinergic Burden Score — tool for assessing cumulative xerostomic risk in the polymedicated patient. reference

10. Prevalence of polypharmacy and drug interactions in geriatric patients — cross-sectional study, definitions and prevalence. 2023-2024. 2024

11. Université de Lorraine. Polypharmacy in the elderly: study of characteristics and determinants — French data on hospital iatrogenesis. study

12. Public medicines database. Various SmPCs — drug interactions, geriatric adjustments. reference

13. FDI World Dental Federation. Oral Health for Older People — general recommendations for geriatric oral health care. reference