S4 E01: Weight Loss Drugs and what dentists need to know

Wright: [00:00:00] Hey, hey, friends. Welcome back.

Ioannidou: [00:00:03] Welcome back. I'm so happy to be back, people.

Wright: [00:00:05] We're so excited to kick off season four. It's going to be full of fresh episodes, great conversations and fascinating topics just like today.

Ioannidou: [00:00:15] Hello, everybody. I'm Dr. Effie Ioannidou.

Wright: [00:00:18] and I'm Dr. ArNelle Wright.

Ioannidou: [00:00:19] I'm so excited that we are doing something that is really on the top of the headlines, right?

Wright: [00:00:25] Yeah, me too.

Ioannidou: [00:00:26] This topic today and everybody's talking about the GLP-1 medications for weight loss. To be honest, I was not very familiar. I dug into this and I learned a lot to get ready for our discussion. And this is really very interesting. So I think today it's the right time for us to learn how to navigate the challenges that may present when treating our patients.

Right?

Wright: [00:00:48] Yeah, absolutely. Now, before we get started, we do have a little favor that we want to ask everybody. If you've been enjoying the Dental Sound Bites podcast, please help us by rating the podcast on Apple Podcasts, Spotify, or wherever you are listening.

Ioannidou: [00:01:03] And more importantly, leave a review. We listen to you. This helps us so much support ourselves, but also other dentists and the great profession.

Wright: [00:01:12] Absolutely.

Announcer: [00:01:14] From the American Dental Association. This is Dental Sound Bites, created for dentists by dentists. Ready? Let's dive right into real talk on dentistry's daily wins and sticky situations.

Wright: [00:01:30] Well, hello. Hi Effie. It's been a while.

Ioannidou: [00:01:33] I haven't seen you for… actually, I see you on social media. I cannot follow through, you know, you're so active.

Wright: [00:01:41] Oh, thank you

Ioannidou: So much energy.

 Wright: Oh my gosh. I try. I try very, very hard.

Ioannidou: [00:01:48] I think I post only when I'm forced to post. No, I'm not forced, but I have to. So like after every meeting or, you know, advocacy day. So then I do it, but then I have a very big decline.

Wright: [00:02:01] Yeah, yeah, yeah, yeah. I know. I just love being on there. It's kind of like a little break for me from everything, actually. Social media is just such a part of everything that we do every day. I feel like it's like our resume. People go and look there first before they do anything, you know?

Ioannidou: [00:02:17] Yeah. It's your electronic footprint.

Wright: [00:02:19] Exactly. I was just going to say, it's my digital footprint. So, you know, I try to stay current.

Ioannidou: [00:02:24] That's why you have to be very careful what you put out there. Because it will last forever.

Wright: [00:02:29] Very true. Oh my gosh. Okay, I'm totally not ready, but listen, I try to be very intentional about what I put out there. I'm not gonna lie.

So, we want to welcome you all back to Season 4. We are so, so excited to be kicking off this new season. Yeah? Let's jump on into all things GLP-1 and Ozempic. Yeah?

Ioannidou: [00:02:51] And this is, you know, it's another thing that shows how important the feedback is for us, right? We have been listening to our audience, to our listeners. This is a topic that they ask for, and we have the expert here with us to discuss about the GLP-1 weight loss medications in dentistry. So let's dive into this, ArNelle. Let's do it, girl.

Wright: All right. We are so excited, everybody, to have Tom Viola joining us. He is a board certified pharmacist, educator, speaker, and author with a knack for demystifying pharmacology for dental teams.

He's also a consultant to the American Dental Association's Council on Scientific Affairs. Welcome to Dental Sound Bites, Tom.

Viola: [00:03:35] Thank you so much. It's such a pleasure to be here and such an honor to be spending some time with you today. I've listened to the podcast. I've enjoyed it all these years now. It's been two years since I've been listening.

Your banter and the topics you've had have been so interesting and so topical that I've enjoyed a lot of, uh, listening. And so I'm glad to be a part of it. Now, I will promise I'll not listen to myself. Okay. So how about that?

Wright: [00:03:58] Oh, you have to.

Ioannidou: [00:03:59] Tom, help us understand the mechanics of this weight loss medications. Where did they come from? How do they work? During the weekend, I try to follow some review papers. There is a lot of information there and it's really quite interesting. Are they exactly the same medications with what we have been using to treat diabetes or are they different? Then we can actually dive into why do we need to care about the use of them in dentistry?

Wright: [00:04:26] Yeah.

Viola: [00:04:27] Absolutely. You know, the history of type two diabetes and weight loss, those histories have been intertwined for quite some time now. We've been doing research on these peptides for, as it turns out, over a hundred years. But so many people have played a part in it. It's hard to put the praise or the glory on one person, because so many scientists have contributed to it. Honestly, it really all started with, of all things metformin. When we first discovered type 2 diabetes as a disease in and of itself, we were confounded because we really were faced with older patients, you know, let's say in their 60s and 70s, who weren't making enough insulin.

And so our simple minded approach to the treatment of type 2 diabetes then, based on that knowledge, was, well, let's just give them drugs to help them make more insulin. And those are the drugs, you might remember the sulfonylureas, glyburide, those drugs. And then we realized that their pancreas was not making enough insulin because basically it was burned out from overproducing insulin for so many years.

So it wasn't that we had some 60 or 70 year old who wasn't making enough insulin. It was really a 30 year old or so who slowly became resistant to their own insulin, that then became the 60 something year old that had too little insulin production. So we needed a whole new drug to treat it. It wasn't the sulfonylureas, although they had a use and they were certainly effective.

We needed a drug to treat that type 2 diabetic back when they were in their 30s and developing insulin resistance. And so the drug that we ultimately came up with was metformin. There were others, the glitazones, rosiglitazone, pioglitazone.

Ioannidou: [00:06:10] Right.

Viola: [00:06:10] But metformin really was the drug, and it did exactly what we asked of it. It increased insulin sensitivity and decreased insulin resistance. So that by the time that 30 year old became the 60 year old, there wasn't as much damage to their pancreas, there wasn't as much drop off in insulin production, which was amazing. But, metformin did something we didn't ask it to do, and that was cause weight loss.

Wright: [00:06:34] Weight loss, okay.

[00:06:35] That was what opened the Pandora's box, you know. People realize all of a sudden now they can take a drug that wasn't fen-phen that allowed them to lose weight. Well, I'm all for it. Whether or not it's being used for type 2 diabetes, I don't care. It's going to make me lose weight. I'm happy about it.

Well, think about it from the type 2 diabetics perspective. This is awesome because this drug treats my type 2 diabetes, improves my lipid profile, and helps me lose weight. That's a hat trick, right? That's what, what more could I ask?

Wright: [00:07:05] Yeah.

Viola: [00:07:07] But, while metformin allowed for weight loss, it was modest weight loss. And that caused the push towards finding another drug because we then introduced the term prediabetes. A lot of folks are diagnosed as prediabetes or prediabetic. And they decide, well, since I'm prediabetic, I don't really need to do much, I'll just wait until I'm diabetic enough. Can't say that was everybody, but it was enough people who now, because they had elevated blood glucose and weren't seeking treatment, they ultimately suffered organ damage from those elevated blood glucose levels over so much time.

Again, prediabetic. Not diabetic enough. That's up for grabs, but let's put it this way. That's why diabetes is an underreported cause of death in the U.S. Because a lot of people die of the ramifications of diabetes, never having had diabetes listed on their death certificate in the first place.

Ioannidou: [00:08:01] That's absolutely right. Yeah.

Wright: [00:08:03] That's a different conversation, huh? It takes us a lot deeper.

Viola: [00:08:07] So this is leading somewhere. So, okay, now I have organ damage and now, ironically, I am not a candidate for metformin because I really can't take metformin if I have liver or kidney issues. Now I'm the perfect candidate for metformin who's not a candidate for metformin. The one drug I've been waiting to take all these years because I've been prediabetic and now I'm diabetic, I can't take the drug because I've got this organ damage. 

What do I do now? Well, these people need a hero. And who's the unsung hero of all these type 2 diabetics who couldn't take metformin? Well, through a lot of research and development, turns out it's the humble Gila monster.

How many people know what a Gila monster is, or the fact that it actually is spelt with a G, but pronounced as an H? And the Gila monster is a reptile that lives in the desert, spends most of its time on the ground, let's say 95 percent of its time on the ground. To see one is pretty rare, but if you see one and it bites you, you're not going to be happy because it won't kill you, but it'll, it's very painful.

But from that we discover what? The Gila monster's bite is venomous and it causes, in some cases, enlarged pancreas. Why would that be? Obviously, there's something in the Gila monster's venom that has something to do with the pancreas. Well, as it turns out, through research, we find out that the Gila monster is curious because when it spends all its time underground, it can go weeks without eating, and it can go into a sort of semi-hibernation waiting for its next meal, but yet its blood sugar stays stable and its appetite is nonexistent.

Ioannidou: [00:09:48] I want to be a Gila monster.

Viola: [00:09:50] Me too.

Ioannidou: [00:09:51] That sounds pretty good.

Wright: [00:09:53] Sounding good.

Viola: [00:09:54] So what happens?

So it's a peptide in the Gila monster's saliva that when it swallows it, suppresses its appetite, slows down its gastric emptying time, right, and stabilizes its blood sugar. Well, if I'm an endocrinologist, there are light bulbs going off in my head right now because I'm saying, that sounds like a great treatment for type 2 diabetes.

And so research goes on and it turns out researchers want to know if these reptiles make this hormone – this peptide – why don't we make it? Because they know us humans are not far off the reptilian evolutionary tree. Some humans more than others. So go find it.

And it turns out that it's the incretins, but we had known about the incretins for a while at that point, but still, the incretins are these hormones or peptides that can do the same thing in humans, except ours don't last very long. They wouldn't be effective as a drug.

The Gila monster's hormone or peptide, when given to humans, does work, but it doesn't last long enough, you got to dose it twice a day. It becomes the drug Byetta, which had modest success. Once we start developing these drugs into longer lasting drugs that can be dosed once a week, that's when we get things like Victoza and Trulicity, and of course ultimately Ozempic and the latest drug is Mounjaro.

So I call them synthetic incretins. But everybody else calls them, you know, the drug that's going to make them get the body they always wanted. And that's because they do help you suppress your appetite and they do help you lose weight.

Ioannidou: [00:11:43] Yeah, but they all come, you know, they cannot be a drug that has all only positive outcomes, right? I'm sure they all come with some type of side effects or adverse events, correct?

Viola: [00:11:55] Correct. And this is the thing, you know, it is a lot of happiness when you can find a drug that you can take that will help you lose weight in a controlled fashion, but get the results you're looking for. Because weight loss is always such a stubborn process for so many that, you know, there's psychosocial and other behavioral problems that can occur that make you want to eat, that make you desire carbohydrates. So many things can derail you, that to find a drug that is dependable in helping you lose weight, it's really amazing.

But the problem, of course, is the drug is designed to treat type 2 diabetes, not necessarily weight loss. What do we do now? So when Trulicity is introduced, we know that it can cause weight loss. As a matter of fact, it's mentioned in the commercials. Not in the beginning, because the FDA really doesn't want you to promote weight loss. It's more towards the end, like, oh, and by the way, I can lose a few pounds. 

When Ozempic is introduced, the weight loss is so dramatic that the company that makes Ozempic files for two patents: one for semaglutide to be used to treat type 2 diabetes and, two, semaglutide to treat obesity to encourage weight loss. And gets both patents awarded.

And that's why you've got the same drug, semaglutide, marketed as Ozempic and Wigovy. The technology takes off so well and is so effective that the company also produces oral tablets called Rybelsus. Now that's a breakthrough because everything else we have is injectable. Oral tablets to lose weight? Wow.

Ioannidou: [00:13:29] Of course.

Viola: [00:13:30] And then, of course, not to be outdone, Mounjaro, the latest drug. works even better than Ozempic because the two peptides that are responsible for all of this are gastric inhibitory polypeptide, GIP, and glucagon-like peptide or GLP-1. Mounjaro works on both. So it has a greater mechanism of action than Ozempic does.

Ioannidou: [00:13:56] Mm hmm.

Viola: [00:13:56] And so Mounjaro gets its notoriety for weight loss. And again, that same drug now is marketed as Mounjaro for type 2 diabetes treatment and Zepbound as a drug for weight loss. So from the lowly Gila monster, my friends, very long winded story, we get the drugs that everyone's talking about these days.

Wright: [00:14:16] I'm so glad that you ended with the drugs that everyone's talking about these days. How long have these drugs been in rotation? Are we just now catching the hype because of social media? Like how long have they been being used?

Viola: [00:14:28] I first heard about Ozempic in my field 'cause I'm the pharmacologist, so I kind of get the first wave of things that are coming that will become popular. And so I heard about Ozempic and weight loss probably about two years ago.

Wright: [00:14:42] Okay.

Viola: [00:14:43] But then what happened, as I'm sure we just talked about earlier, a lot of influences on social media started talking about Ozempic.

Wright: [00:14:50] Yeah.

Viola: [00:14:51] And it became so popular, we ran out, if you can remember.

Wright: [00:14:56] Yeah, yeah, I've heard about it.

Viola: [00:14:57] Out of it last year.

Wright: [00:14:58] A lot of the story has, like, gotten my wheels turning as it relates to dentistry and patients waiting for things to happen. But, now that we have kind of high a level on Ozempic and, you know, some of the GLP drugs or semaglutide, why would dentists be interested in knowing more about this drug? What are some of those known systemic effects on overall and oral health?

Viola: [00:15:21] But that's the nature of what I do for a living, right? So my job is to make pharmacology practical and useful for the dental professional, right? Because it's great to know about 3,000 mechanisms of action, but if you can't put the knowledge to work, what good is it having all that knowledge?

So here's my first problem, okay? And I say this a lot during my lectures. It's all about the medical histor. You've got to be able to take a complete and accurate medical history.

Now here's where it gets sticky. I'm your patient. I want to be as upfront with you as I can about the drugs I take. I take Ozempic. But that's all I say. I take Ozempic. If you're the seasoned dental professional, you hear Ozempic and you say, Oh, this person must have type two diabetes or maybe they have prediabetes.

No, I'm using it for weight loss, but I didn't tell you that part. So you may make a whole bunch of assumptions about the treatment planning for that patient thinking they're prediabetic or diabetic, not realizing, no, we should have went this way. It's more being used for weight loss. So that's the first problem.

The second problem is the opposite effect, which is, I'm on this drug and I don't tell you about it. Because there's a stigma attached to it. I don't want people to know I'm taking it. Maybe I got it from alternative sources. So I don't say anything, but the drug can cause hypoglycemia.

You put somebody in a stressful situation and, you know, let's say they haven't eaten because nobody likes to eat before they see the dentist or the hygienist because, you know, food in my teeth. And now they're 20 minutes into the procedure, tank's running empty because I'm, you know, all my glycogen is gone and I'm starting to go hypoglycemic.

I didn't think you'd be going hypoglycemic this quickly as your dentist because no one told me you were taking Ozempic. So it's a dual-edged sword. And the other thing is, as the good doctor said, there's always going to be some side effects. Okay, so like what? The first thing I'd worry about is everybody wants to take enough Ozempic to lose weight. That's great. But when you get down to that last 10 or 20 pounds, those really stubborn 10 to 20 pounds, that just don't want to come off, you have a tendency to want to take more and more to get that weight off. And that can lead to, unfortunately, stasis, where basically you get gastroparesis. Because you've suppressed the gastric emptying time so much that there's no movement.

And that's unfortunate because now if you do eat, the food doesn't go anywhere. So either you're going to vomit it back up again later, or it's going to sit there long enough that when you open your mouth to say something, someone's going to say,

Ioannidou: [00:17:48]  wow,

Viola: [00:17:48] Wow. Your breath is…

Wright: [00:17:51] kicking

Viola: [00:17:51] atrocious! Your breath is kicking.

Ioannidou: [00:17:54] So that's why the Atlantic came up with this article, the Ozempic Burp.

Viola: [00:17:59] Correct.

Ioannidou: [00:18:01] And I was like, huh, that's an interesting term to start a paper.

Viola: [00:18:04]  No, no, not because you said, right, I get this Ozempic Burp and someone tells me, wow, your breath is kicking. Where would I go to get that checked out? I'd go to see my dentist and say, why did the guy on the bus say my breath was rank.

What's going on here? I brush and I floss. They don't floss, but you know what I mean? So why is my breath so bad? Uh, it's not this, it's that. But if you didn't tell me you were on Ozempic, I might spend, I don't know, three or four appointments trying to figure out why your breath is so bad, never knowing it's the Ozempic that's causing the gastroparesis.

Wright: [00:18:39] Yeah. Tom, you mentioned the seasoned dental professional may hear Ozempic. I feel like some of our new dentists who may be listening, they may be, you know, up to speed just because it's so popular online. But for the person who may have never heard about it, like, what if they do not sit up and, and, you know, lean into those conversations? Like, do you have any advice for that? Just maybe going back to the drawing board and asking more detailed questions, I would assume?

Viola: [00:19:06] Oh yeah. So if you add up the fact that, okay, semaglutide, and I'm not picking on semaglutide, it could be any one of those synthetic incretins. Okay. I just use those up because it's the most popular name people recognize.

But if you recognize that it can cause halitosis, right, that it can cause gastroparesis, these are all things the dental professional needs to know. And it's the same combination of things I've talked about in my lectures for years. The first is, how do you take a great medical history? Ask three questions, right?

What do you take? Don't ask, don't say drug, don't say medicine, right? Because people assume you mean little bottles, right? What do you take? Give me everything, right? Dietary supplements, whatever. Give me everything, right? 

Why do you take it?

Wright: [00:19:48] Yep.

Viola: [00:19:49] Because you don't always know. Right? Uh, I said I'm on Ozempic. You say, okay, why do you take it? Oh, it's for weight loss. See, I just solved that problem. Now you told me why. Now my students hear me say this and they say, but I'm supposed to know, right? Why? No, you don't know. That's the whole point. You have to ask. What do you take? Why do you take it? 

And of course, the third question is, did you take it today? And saying it over and over again really extracts the information from your patient. And because a lot of times people don't want to tell you anything about themselves. They don't think you need to know, because you work up here.

Wright: [00:20:20] Right.

Viola: [00:20:21] And you're a stranger. And I don't want to tell you too much, because then if I tell you too much, you're going to say, I can't treat you today. So I'll just kind of say nothing. But pharmacology is the Rosetta Stone. Right? All I need is a working knowledge of pharmacology and a list of medications you take and I can fill in those blanks. You just got to tell me so I know, and then I can fill in all the other stuff maybe you don't want to tell me.

To your question, Doc, in a very roundabout way, for the newer professional, remember that these drugs are used for weight loss, they are used for type 2 diabetes. You've got to get to the bottom of that. And so my advice for all the dental professionals that attend my courses is, be the bartender. To be the bartender is my way of saying, you know, for years I was a bartender. And the one thing I learned was you have two ears and one mouth, right? So use them in that ratio. Do more listening than speaking. Because sometimes as a bartender,

Ioannidou: [00:21:16] I like this.

Viola: [00:21:16] people want you to listen. Okay. Just listen to me. Right?

Ioannidou: [00:21:21] Yeah. And this is really important. It's important to avoid assumptions. As you said, that even for people that know Ozempic, they may immediately assume that you are diabetic or prediabetic. And then the misunderstanding starts, right? I mean, it's so easy if you instead of assuming you can, you know, you can ask also questions about what was your last hemoglobin level. You know, like, so you can get a better, and dive deeper into what's happening.

Wright: [00:21:50] Oh my gosh. I feel like my patients tell me all kinds of stuff. I found out about the medication from a patient, like one of my patients. I was like, Oh my gosh. And she actually did use it for weight loss. That's kind of how I found out about it. Like, and then once I learned more about it, I'm like, Oh my gosh, I've been hearing this on TV for how many years? And I just never paid any attention. Yeah. Cause it just didn't apply to me. But I feel like my patients tell me all all kinds of stuff. And I'm like, Whoa. 

And, and to your point, Tom, I actually do take a moment. I kind of, like, just crouch back on like this little, the counter that I have in one of my ops. And I just kind of sit there and I'm like, okay, tell me what else is going on. I like dig and dig and dig. My staff, yhey're usually in the back, like, come on, I need you. And I'm like, I just need need information. But, you know.

Ioannidou: [00:22:38] And that's good. No, but going forward, like, so you have all this information, right? So now, as dentists and, you know, our dental teams too, what should we be mindful of in the management of the patients that take the Ozempic? What do we need to be aware of? What are we dealing with?

Viola: [00:22:59] I think it's education. I think you serve a great purpose here in educating your patient about this drug that they may have obtained through whatever measure and not really know what to expect.

And so as a dental professional, as I've always said, you're really the dental slash medical professional because you're, you're not just giving great dental care, you're dispensing information too. And so if I have a new patient who's new to Ozempic or who's been taking it for a while, I'm going to mention the things like, okay, if you discover that you've got this Ozempic Burp or people tell you your breath is kind of, you know, a little over the top, or if you've noticed that you, when you eat something, it doesn't sit well and maybe sometimes you feel like vomiting.

Heck, I want that patient to know that because I want them to know what to expect. But also I want my team to hear it because let's say I'm using Ozempic. I don't tell anybody. But because of the gastroparesis, I vomit a lot. Well, if I come to see you, you're going to look at my mouth and say, okay, this is either GERD or perhaps an eating disorder. Or something else going on. Maybe it's cannabinoid hyperemesis syndrome, where people vomit multiple times a day from using too much cannabis. I need to know all that, but it started with a conversation about Ozempic.

Ioannidou: [00:24:12] Yeah. Say that the patient comes to me as a periodontist because of their halitosis and, you know, whatever, we solve the issue. We give some oral hygiene instructions. And then we do know that the patient takes Ozempic and the next step, you know, the patient is diagnosed with periodontal disease, severe disease, and may need surgery and chooses that the best mode of the surgery will be combined with some type of sedation, right? So tell me a little bit about this, how we deal with the anesthesia issue on a patient that takes Ozempic.

Viola: [00:24:45] So that's why it's so important to find out if they're taking Ozempic and if they have some type of issues where they're vomiting, even on occasion. Of course, you all know that the danger of someone vomiting when they're under sedation, so we want to know that that's not something that we need to be wary of. It doesn't happen in every patient, thank goodness, but it does happen enough that it's a concern. If we don't ask the patient, because if I was taking Ozempic and I was taking enough of it to make me vomit, I may have a stigma in my mind thinking, I don't want to say that because they're going to think, why would you do that? Is it that important to lose weight? Well, for me it is. Yeah. So I'll do it for me. But now I don't realize because of what you're going to do, I'm putting my life at risk. So again, it's going to be education. It's going to be finding out as much as you can about the patient. And again, whether you're the seasoned or the new clinician here, you've got to know that these drugs have far reaching consequences, even beyond just the effect on the dentition. In this case, and well put, doctor, it could even affect the sedation you use and how closely you monitor the patient while they're under sedation.

Wright: [00:25:50] We'll be back.

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Ioannidou: [00:26:48] Now, here with us, we have the expert to discuss about the GLP-1 weight loss medications in dentistry.

Wright: [00:26:55] Absolutely. We are so excited everybody to have Tom Viola joining us. Tom, can we talk about potential interactions? So, back to your initial point about having a very detailed medical history, what are some ways that we can have these conversations?

Or maybe even if I were your patient, I'm coming in, you know, I'm taking this medication or maybe I don't put that I'm taking this medication on the medical history. Maybe I just say that I do have diabetes. Would it be appropriate to say, have you ever heard of this medication? You know, maybe we can role play through, like, what could some of those questions be that a clinician could ask to dig and kind of get some background about the situation?

Viola: [00:27:38] No question about it. This is a perfect opportunity for you to use some of that knowledge that's been stored in your brain for so long. If I have a patient who says, well, I use Ozempic, and I don't get much more conversation than that. Then I'm going to ask some of the questions that I'm sure you'd be ready to ask yourself. Like, Oh, really? What was your last A1C? Oh, well, I don't know what that is. Well, okay, how can you use the drug for diabetes and not know what an A1C is? What was your last fasting blood glucose? Oh, I don't know. I don't think I've ever had that. Most diabetics have that test.

Wright: [00:28:11] Most of them, they know.

Viola: [00:28:13] I'm forging the road ahead of me. Like, okay. So I'm getting the idea that using Ozempic, you know, for more for weight loss, or maybe, you know, cause your cousin gave it to you, you know, ‘cause they didn't want to use it themselves. But if I ask those questions and you say to me, Oh, my A1C was, you know, 6.3 and my fasting blood glucose was 121. Okay, well then I know you're probably someone who's using it for diabetes and I can ask more questions down that line. If you're using it for weight loss, I'm not looking in your mouth for the obvious signs of someone who has type 2 diabetes. Yeah. But if you say you're using it for type 2 diabetes, well now I've got a better idea of my treatment plan.

Wright: [00:28:49] Right.

Viola: [00:28:50] I'm gonna note it to look for the obvious signs of type 2diabetes. So, all of that rolls into really, again, taking the medical history and getting the best answers to the best questions.

Wright: [00:29:01] Can you talk to us about a little bit of the potential interactions that are like maybe the top two or three interactions that GLP-1 medications may have with other drugs, or I know it's probably on a case by case basis because everybody takes something different, but maybe some primary ones to look out for?

Viola: [00:29:21] Sure. No, keep in mind, there are really very few direct drug interactions with these. Which is good, right?

Wright: [00:29:27] That's good to know. Yeah, yeah.

Viola: [00:29:28] But it's a lot of the indirect. So, for example, you know, someone's using this drug, Ozempic, for weight loss and we know it can cause hyperglycemia. But yet we know that we use drugs in dentistry that can alter blood glucose levels, right? We sometimes use corticosteroids. We know steroids can raise blood glucose levels, right? We use epinephrine every day in dentistry. We know that can raise blood glucose levels.

So you can see that as a sort of indirect drug interaction, right? At the same time, you know, we used the procedure itself, you know, whatever procedure we're doing is stressful for the patient and that can cause them to, I would say, release a lot of glycogen into glucose in their bloodstream.

And now, after about 20 minutes, as I said, their blood glucose starts to plummet. So I've got to be able to plan for that as well. I mean, that's a medical emergency. So do I have glucose in my office? Is it in my emergency kit? Have I looked at my emergency kit lately? If the patient's unconscious, am I trained in the use of injectable glucagon to bring them back?

That's all my thought process when someone says they use Ozempic, because I'm looking at them as someone who could potentially develop hypoglycemia. By the same token, let's not forget, much like cholesterol medications, some people think that if they're taking Ozempic, they can eat whatever they want and then they get hyperglycemia, which is ironic.

And so then I'm worried about looking for the obvious signs of ketosis and, and you know, what others that can spur on, you know, caries and all sorts of complications, like someone who's an uncontrolled diabetic.

Ioannidou: [00:31:01] And I know we have used the generic term, we talk about Ozempic all the time now, but in general, everything that we discuss, does it really apply to every generic GLP-1 medication or do you find that there are degrees of side effects?

Wright: [00:31:16] That's a great question.

Viola: [00:31:17] Yeah. So I love the question, Doctor, because I certainly don't want anyone to think I'm picking on Ozempic, right? All of these drugs just become like Kleenex, right? So it's, you know, I think it started with Trulicity and every one of those drugs bears the burden of that stigma in a way or that potential fault is that, you know, they can cause these side effects. They can cause these problems that we've been discussing.

I would like to say also that for some folks, it's going to be a difficult conversation. You know, obesity is a tough subject to talk about anyway. A patient's using Ozempic to lose weight. Some people view that as, well, you're taking a shortcut, right? Why didn't you just put in the work, stop eating, exercise more. I get that. I'm completely sensitive to that, but at the same time, I want us to be able to have that conversation with our patients and realize for whatever reason they decided to use the Ozempic, that there are those folks that may not ever be pleased with the way their body looks.

And one of the examples I can, two of the examples I can give you is some patients who use Ozempic say that, and again, let's, let's, maybe we'll call them these Ozempic drugs. Okay? Ozempic-like drugs. Yeah, we can sayI lost too much weight. Now my face looks too thin, and then the term has become Ozempic face.

Ioannidou: [00:32:44] It should become European face.

Viola: [00:32:49] Right, I have too little fat on my face now. And of course, I hate to use the word, but Ozempic butt is another one. Like, I've lost so much weight. My butt is now flat.

Ioannidou: [00:32:58] Wow. I have no idea. I don't know any of these guys. Like, where do I live? It's a different world.

Wright: [00:33:05] No, well, this is Tom's world. So he's educating us big time. 

Ioannidou: [00:33:10] That's really good. I love this. But you're absolutely right, Tom. There is a stigma for sure. And that's why people are reluctant to share exactly what they are doing, especially if this is not prescribed appropriately, right? Via a physician, a diagnosis, specific BMI cutoff, as we discussed. So if it's done because your cousin or your friend, or, you know, you travel to whatever country and you found it easily accessible and you decided, you know, why should I exercise? Let's do this, which is an easy way. I have to say.

Viola: [00:33:44] Exactly. And I would say, you know, I've been painting a little bit of a negative picture, but Ozympic has helped so many people treat type 2 diabetes and help them lose weight responsibly and in a healthy way that it is a very positive thing. It's just that we tend to look at the negative because that's a lot of what we hear in the news. You know, Oh, look at this. Now we have Ozempic butt. You know, I don't want anyone to think that, you know, things are going to go bad for them if they're using Ozempic or any drug like it, because actually these drugs are quite popular for a reason. They work and they work really well.

Ioannidou: [00:34:13] And are they evolving? Because the side effects that you mentioned are pretty serious. The stasis and I mean, that's significant. I mean, do we have new classes or evolution of the drug manufacturing, if you will, that addresses the side effects or any other, any other actions of the drugs?

Viola: [00:34:35] We're learning as we go. That's the thing is, this is an evolution in progress. We're learning every day as we go, as we have a greater and greater exposure to a greater, greater population base, we're going to get more and more reporting back. Again, with that same stigma, some people may not report that they didn't have the best results, you know, and some people will report they do.

But, you know, again, we tend to focus on the negative and not so much the positive when it comes to this. So I can tell you that at some point, like Mounjaro. really is an evolution because it now works on both of the incretin hormones versus the single agent ones before. And who knows what's going to come next.

I mean, from what I gathered, there's a drug that's in the pipeline now that's going to be working on the three different receptors. So the GLP receptor, the GIP receptor, and even the glucagon-like receptor, which will produce even greater weight loss.

Ioannidou: [00:35:24] Yeah.

Viola: [00:35:25] The drug's still in transition right now. It's still in experimental phase, but imagine when that drug hits the market. But see, all of this experiential learning means we'll be able to, number one, as clinicians, be able to recognize the potential pitfalls, but also maybe,to your point, we're able to create a drug that is not likely to cause as many of the pitfalls as we've uncovered earlier in our experience with these drugs.

Ioannidou: [00:35:49] Yeah. Oh, that's interesting. No, I mean, this is really very, very useful. I really like the conversation and, you know, definitely very useful for our community, right? Like for the dental community.

Wright: [00:36:03] There may be people who are listening that they may be prediabetic or they may be diabetic and they are providers. Do you have any, like, thoughts or any words outside of anything that you've already shared to maybe help them navigate their own journey with using GLP-1 medications or any of those?

Viola: [00:36:22] If I was a clinician right now who had type 2 diabetes and had listened to this podcast, I would be a little, a little scared right now listening, thinking, well, all these points that we brought up, you know, collectively and all of this potential grief that could happen to me using this drug, maybe I don't want to use this drug, you know, maybe it's a little bit too risky.

And to those people, I would say the best thing you can do for type 2 diabetes is treat it. Because we know that it's a progressive disease that will ultimately cause you to deteriorate and it is eventually fatal in some way or another. And these drugs, all of these drugs that are incretin mimetics, you know, everything we just talked about, including Ozempic and Trulicity and Victoza and Muonjaro, these drugs are safe.

You know, the FDA approves these drugs because they've been proven to be safe and effective. So don't be scared just because you heard a lot of what we said today and think, well, gosh, maybe I don't want to use that drug. Now's the time, you know, it's never early enough to treat diabetes when you know you have diabetes.

And that was my problem with the word prediabetic. As I said before, a lot of people thought they were prediabetic and therefore didn't need treatment. And my example to my students as always is, you know, if you think you're pre anything, it's like saying you're a little pregnant, you know, you got it. So treat it.

Right. So don't wait because waiting or, you know, saying, I don't know if I want to try that yet. Let me, let me try something else first. If you've been prescribed a drug, take advantage of it, and use it, and use it responsibly. And, you know, that's why the FDA exists.

Ioannidou: [00:37:57] Well, this is a very good point. So please leave us with your top three recommendations or things to implement right now in our practice to be better prepared when treating patients using GLP-1 medications.

Viola: [00:38:11] So first one is to take a complete and accurate medical history.

Wright: [00:38:14] I got that one. I'm going to be on top of that one now.

Viola: [00:38:17] And I say this and I'm in my lectures and a lot of doctors look at me and say, I don't know if you realize this, but I don't even have time to eat lunch and use the restroom. And you want me to spend 15 minutes going over medical history? 

Ioannidou: [00:38:28]Yeah, it's your job. You have to do it.

Viola: [00:38:30] But you know, train your staff. You've got to staff for a reason. Everybody walks in that operatory asks two questions and fill in the blanks. Right. And that's how you collect the information. So top recommendation is take the complete and accurate medical history.

Second recommendation. If they say they are on one of these GLP drugs that we talked about today, ask more questions. Okay. So I see you're on this drug, Ozempic, you know, so tell me about it. Again, if I want to get more information out of you as far as what you're using it for, I can ask directly, what are you using this drug for? Or I could say, you know, what was your last A1C or how long have you had diabetes? Oh, I don't have diabetes, I use it for weight loss. Okay, good. So it became a non confrontational approach, right? You didn't ask directly, sort of indirectly, right? So that's the second recommendation that works. 

And the third recommendation is start clicking off in your brain what you would do in a scenario where there's hypoglycemic, you know, the issue of hypoglycemia and a hypoglycemic reaction, which can be due to the medication or the stresses involved in a dental visit, right?

And think about what you're looking for in the mouth. What potential indices there are in the mouth as far as, are you looking for decay? Are you looking for, you know, xerostomia due to elevated blood sugars and therefore frequent urination? And ironically, and I've been saying this a lot more lately, ironically, some people who use Ozempic to lose weight may actually be diabetic and not be diagnosed. So they're obese because they're type 2 diabetic. They don't know they have type 2 diabetes, but they're taking a drug to lose weight and inadvertently treating their type 2 diabetes. They're not skilled in that. They're not a clinician. They have no way of knowing how to use that drug to treat their type 2 diabetes.

So you may uncover.

Ioannidou: [00:40:22] From the manifestations in the mouth. Right.

Viola: [00:40:26] Correct. All manifestations lead you to the diagnosis of, wait a second, maybe this person is type 2 diabetic and coincidentally is using Ozempic for weight loss. And so that's where consultation, you know, bringing that patient to the awareness, say, you got to go see your medical doctor.

You know, you gotta get this checked out because this is important. This is what I've found in your mouth. This is what I see from your medical history. Consultation is everything these days. I've often said this, too, people love to see their dentist. Why? They love their pearly whites and they may see their dentist more than they see their medical doctor.

So if you're the one asking all the questions, you're the one taking their medical history and taking their blood pressures and you're doing all that, who's really taking care of this patient? So we can have discounted the role that dentists play in good healthcare, not just oral healthcare as well.

Wright: Well, thank you for that.

Ioannidou: [00:41:12] That's good. I love the conclusion. That's really good. And I really like the point that you made in terms of the fact that we as dentists have to be aware of the, you know, specific manifestations in the mouth, but also the management. How you really adapt to the use of this medication and make sure that you kind of, you're prepared for potential adverse events.

Viola: [00:41:36] Absolutely. If you're not, if you haven't taken a course on how to treat medical emergencies in the office, I highly suggest it. I don't teach it, so that's not self-promotion. I just think, you know, you should take a course on that at least once a year. Be, be fresh because things change all the time. You know, be up to date on the treatment so that you can be effective and efficient.

Ioannidou: [00:41:54] Yeah, very good point.

Wright: [00:41:55] Yeah.

Announcer: [00:41:56] On the next Dental Sound Bites.

Wright: [00:41:58] Join us for an important episode on depression and suicide affecting our profession. Our special guest, Dr. Karen Foster, will share vital information, guidance, and support resources.

Ioannidou: [00:42:13] Thank you so much. This was a great, very useful session. I love it. It was great. Thanks, Tom. This was helpful. It was a lot of new knowledge for us, but not for ArNelle. She's very informed. She's on top of it. But I have to say that I was not very familiar with the medication and it was an opportunity for me to go back and look into the mechanism of action and the side effects. It blew my mind. 

As we said, there is not a single medication without side effects. It's not the only class of medications that it's not new to us. Right. But we have to be prepared.

Viola: [00:42:52] Viola: And I love talking to both of you. Cause you know, I learned from you, I learned the part about dentistry that I don't know. When I give my courses, I always tell people, you know, they say, why are you on the road so much? Why do you lecture? What drives you? And the drive is because when I came to dentistry, I'd known nothing about dentistry and everything about pharmacology, nothing about dentistry. So every time I talk to dentists, I now get to see things from your perspective.

Ioannidou: [00:43:17] Yeah.

Viola: [00:43:17] And so you taught me today. Thank you very much. The other side of this, which is, okay, I'm a dentist. I don't have this pharmacologic knowledge, but here's my patient. What questions do I ask? How do I start? How do I begin this conversation?

Yeah. So thank you. Cause I learned a lot from you as well.

Ioannidou: [00:43:32] So, Tom, tell our listeners, how can they find you? How can they find more about you, where to follow you online, on Facebook, on Instagram or where? Tell us.

Viola: [00:43:43] Absolutely. So, I'm a simple minded man. So my website's easy. It's TomViola.com. It's not hard, right?

Ioannidou: [00:43:48] That's very simple.

Viola: [00:43:50] It's almost too simple, right? So check out my website. I've got lots of stuff on there and podcasts and webinars that I've done and articles that I've written and blog posts, and even some courses you can take for CE. I'm also all over social media, but that handle is Pharmacology Declassified. That's the name of my company. So you can find me at Facebook, Instagram, all of the platforms. Yeah.

Ioannidou: [00:44:12] Oh, great.

Wright: [00:44:12] Awesome. Um, well, thank you so much, Tom, for being here and to all of our listeners. Remember that if you liked this episode, please, please, please share it with a friend, then we want to make sure that you are subscribed to this podcast so that you can always get the latest episodes on Apple Podcasts, Spotify, or wherever you are listening.

Announcer: [00:44:33] Thank you for joining us. Dental Sound Bites is an American Dental Association podcast. You can also find this show, resources and more on the ADA Member App and online at ada.org/podcast.