Taking Your Meds While Keeping Your Teeth: Narcolepsy, Idiopathic Hypersomnia, and Dental Health
(The following is an article which was submitted to the NN newsletter.)
For many people, it's easy to take the health of the teeth and gums for granted. But for a substantial proportion of people with narcolepsy and idiopathic hypersomnia (IH), tooth decay and gum disease can become an increasing problem. This is because medications used to treat narcolepsy or IH can cause changes in the saliva in the mouth for some people. Over time, those changes can gradually lead to increasing rates of cavities and gum disease. With effective prevention, this does not have to happen.
Despite scientific documentation of the potential effects of medications commonly used to treat narcolepsy and IH on dental health, prevention of cavities and gum disease isn't a topic that seems to come up frequently in conversations with sleep specialists or dentists. With a basic understanding of the changes to saliva which medications can cause, you can take charge of how to monitor and protect your dental health.
How can medications affect my dental health?
Many of the medications used to treat narcolepsy and IH cause changes in the contents and amount of saliva for a number of the people who take them. Medications that can affect saliva include stimulants used to treat Excessive Daytime Sleepiness, and tricyclic antidepressants used to treat cataplexy, among others (see Box 1).
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Box 1. Examples of medications which can cause changes in saliva:
Amphetamines: Methylphenidate (Ritalin), Dextroamphetamine (Dexedrine), Dextroamphetamine/Amphetamine (Adderall), Lisdexamfetamine (Vyvanse)
Other stimulants: Modafinil (Provigil), Armodafinil (Nuvigil)
Tricyclic Antidepressants: Imipramine (Tofranil), Amitryptiline (Elavil)
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Normally, saliva protects our teeth in many ways. When there is not enough saliva in the mouth, tiny particles of food, as well as acids and dissolved sugars from food and drinks, can stay in contact with the teeth and gums for hours longer than they otherwise would. In addition, when the contents and/or amounts of saliva are altered, saliva can become less effective in fighting bacteria.
The bacteria that all of us normally have in the mouth thrive in this situation. They feed on the sugars remaining in the mouth. As the bacteria ingest those sugars, they in turn produce more acids. If the acidity on the tooth enamel gets high enough, the tooth enamel can demineralize. That is, the tooth enamel gets weaker as bits of its structure dissolve into the mouth. High acidity is like an invisible thief which steals the strength of one's teeth, one tiny little bit at a time. Cavities are more likely to develop as tooth enamel becomes thinner and weaker.
How do I know whether my teeth and gums are at risk?
Not everyone who takes stimulants for narcolepsy or IH, or tricyclic antidepressant medications for cataplexy, experiences changes in saliva. A medication which causes changes in saliva for one person may not cause those changes for another person. When changes in saliva do happen, many people experience an irritating feeling that the mouth is too dry. They may need to sip water during the day to stay comfortable, and need to drink liquids to help in swallowing dry foods like tortilla chips.
As annoying as dry mouth can be, people who can use that sensation as a signal to start stepping up their tooth and gum care may count themselves lucky. Others have changes in the contents and/or amount of saliva which they cannot detect themselves, despite the fact that the same processes are weakening the enamel of their teeth. Many people in the latter situation are unaware of the changes in their mouths until cavities and/or gum disease begin appearing at higher rates after one or more years of taking the medications. If you have begun taking any new medications within the last 1-3 years which can cause changes in saliva, but you do not experience dry mouth, see a dentist frequently. A savvy dentist can monitor your tooth enamel for demineralization long before cavities begin to appear, and can tell you if it is time to step up your efforts to protect your teeth and gums.
If my teeth and gums are at risk, what should I do?
Fortunately, there is a great deal that people with changes in saliva can do to protect their teeth and gums. One can do a lot to improve dental health no matter whether one has just begun taking medications which have changed saliva, or whether one has already experienced severe decay.
Consider whether it might be possible to switch to medications which might not cause the same degree of changes in saliva for you.
Even when they take exactly the same medications, different people will experience varying side effects. One person may experience dry mouth when taking an amphetamine, yet not have dry mouth when taking Provigil or Nuvigil, for example. Since dry mouth (also called hyposalivation or xerostomia) is a common side effect of many medications, investigate whether any other prescription or over the counter medications which you take regularly could be contributing to the problem.
Ask your dentist to provide you with fluoride trays, and use them once per day.
This is the most important thing that you can do to save your remaining tooth enamel. Applying fluoride to the teeth each day helps the enamel to remineralize and become strong.
Fluoride trays are two soft plastic forms which are made to fit gently over your upper and lower teeth. One places a small amount of prescription sodium fluoride gel into each tray, fits them onto the teeth, and leaves them there for at least 10 minutes. The small amount of sodium fluoride gel which leaks into the mouth should be spit out. If the person being treated is a child not yet old enough to keep from swallowing the gel, talk with the dentist about alternatives.
Whenever you finish a meal, snack, or drink, swish a mouthful of water around in your mouth before swallowing it. And then another.
When you rinse your mouth with water after eating or drinking, you move food particles, acids, and dissolved sugars out of your mouth and down to your stomach, where they belong. Since many people keep a non-disposable bottle of water with them these days, no one will give you a second glance when you sip from yours.
Replace sweet and acidic drinks with something better.
Many people with a sleep disorder and dry mouth understandably resort to drinking caffeinated sugar-sweetened drinks like sodapop, black teas, and coffee throughout the day. Between the high acidity and sugar in these drinks, they are an invitation to rapid erosion of tooth enamel for people with changes in saliva. If it's too hard to replace your favorite sugared soda with water, switch from sugar-sweetened to artificially-sweetened drinks. Coffee lovers can improve their situation by cold brewing coffee to reduce its acidity.
Eat and drink sweetened foods and drinks at one sitting and with meals, rather than over longer periods.
When there are changes in saliva, it would be best for one's teeth if one swore off sweets altogether. But if perfection is elusive, try enjoying your sweets at a single sitting with a meal. The quantities of sugars and acids that we eat are less important to our dental health than the amount of time we spend eating them. And if you eat and drink acidic and sugary things with a larger meal, the increase in saliva which is prompted by a longer period of chewing will help to minimize the damage to your teeth and gums.
Minimize nighttime eating that is not followed by brushing.
Some people with narcolepsy report that they wake and eat during the night and then quickly fall asleep, and/or that they need a snack directly before falling asleep. When sugars and acids are present in your mouth while you sleep, they have a long opportunity to damage tooth enamel. For some people who eat at night, amphetamines are suppressing the appetite during the day, meaning that one can be very hungry during the nighttime hours after the amphetamines have worn off. If this might be true for you, consider experimenting with eating more during the daytime and/or eating a larger dinner to stave off hunger during nighttime sleep hours. (People taking Xyrem are generally advised to stop eating at least two hours prior to taking their first dose.)
Brush and floss a minimum of three times per day.
Be sure to brush and floss before going to bed at night. Saliva production falls by 50% while we sleep. As previously mentioned, sugars and acids which stay in the mouth during sleep can do lots of damage to tooth enamel.
Use a high fluoride toothpaste.
High fluoride toothpastes can be provided by prescription by a dentist. Exposing your teeth to higher levels of fluoride helps them to remineralize and become stronger. Use of high-fluoride products for small children who might swallow them should be avoided.
Use an electric toothbrush.
People with dry mouth have significantly fewer cavities over the course of a year when using an electric toothbrush than when using an old-fashioned manual toothbrush. If the regular head that comes with the electric toothbrush is uncomfortable on irritated gums, try a “sensitive” toothbrush head.
Use a mouthwash which does not contain alcohol, and which may contain fluoride and substances to heal the gums.
Such over the counter mouthwashes include products made by ACT, Bioténe, and Plax. Alternatively, a dentist can prescribe a prescription mouthwash. Avoid mouthwashes which contain alcohol, because they can further dry the gums and delicate tissues in an already uncomfortably dry mouth.
Use sugar-free candies and gums sweetened with xylitol.
Sugar-free candy and gums can increase saliva production. Xylitol is a natural sweetener which protects tooth health by decreasing the level of common bacteria, and by stimulating saliva production. Some Trident gums contain xylitol, and many candies and gums sweetened with xylitol may be ordered over the internet. There are similar products which can be obtained by prescription from a dentist, such as Numoisyn Lozenges.
Two warnings need to be given on this topic. First, chewing gum is not a good idea for people who experience symptoms like bothersome tooth clenching or grinding; popping sounds in the jaw joint; difficulty fully opening the jaw; and/or pain in the jaw joint, cheek muscles, or neck. Both amphetamine use and sleep disorders can contribute to these kinds of difficulties, and chewing gum can exacerbate them. Second, be careful to keep xylitol-sweetened candy and gum away from your dog, as eating very small amounts of xylitol can be life-threatening to dogs.
Use saliva substitutes, particularly before going to bed at night.
Bioténe OralBalance Gel is an over the counter saliva substitute available in drugstores which is particularly effective. Prescription saliva substitutes such as Numoisyn Liquid can also be helpful.
Use a room humidifier, or a heated humidifier attached to a CPAP/BiPAP machine, if dry mouth is uncomfortable during nighttime sleep.
Breathing humid air at night can increase the moisture in the mouth and its tissues, protecting your teeth and gums.
See your dentist once every three months.
Your dentist can monitor the strength of your enamel and the health of your gums, and act quickly to correct problems. It is extraordinarily important to fill cavities quickly, because with salivary changes cavities can get worse many times more quickly than they normally would. If your dental health insurance is limited or nonexistant, seek out dental clinics which are associated with the dental schools in your area. These clinics will often provide low-cost services, and usually accept Medicaid and Medicare.
If you have receding gums or gum disease, ask your dentist about using products such as prescription Perio Protect trays to heal infection and promote gum growth.
Consider using acupuncture or prescription medications to increase the amount of saliva in your mouth.
Certain types of acupuncture treatments have been shown to be effective in increasing saliva flow. Two prescription medications, pilocarpine and cevimeline, are sometimes used to stimulate saliva production. Be sure to explore using either prescription medication very carefully with your physician and pharmacist (including SDS Pharmacy if you take Xyrem), as both pilocarpine and cevimeline can have serious side effects for some people.
What to do when tooth decay is severe
When a person with narcolepsy or IH has taken medications which have caused changes in saliva for many years without adequate warning of how to protect their dental health, tooth decay can become so severe that every tooth is affected. Although a person finding him or herself in this situation may feel that “it is too late” for the careful daily care outlined above, that care in fact becomes even more important. Infections which spread from the teeth and/or gums into the rest of the body can be serious and even fatal.
Simply brushing several times per day with toothpastes which contain both hydrogen peroxide and baking soda, and using a mouthwash such as Plax, can significantly improve the health of your teeth and gums. Even if you have experienced severe decay and the loss of teeth, talk with your dentist about the use of daily fluoride treatments and Perio-Protect treatments to protect yourself from infections.
The author would like to thank Dr. Michael Singer, DDS, FAAMP, FACP, a prosthodontist in Bethesda, Maryland, for his tremendous generosity in translating dental science into plain English; as well as the ten people with narcolepsy or idiopathic hypersomnia who so graciously agreed to be interviewed by the author about their dental health experiences.