Drugs used in dentistry

% of various drugs used in dentistry

• 32 .6% antibiotics• 23.2% NSAIDS• 3.6 % vitamins• Others-antiseptics like chx,listerine

Drugs used in dentistryDrugs used in dentistry

• Drugs used in emergencies

• Drugs used in outpatient basis

The current recommended drugs for medical emergencies are:

• Adrenaline , 1-ml ampoules of 1:1000 solution for intramuscular (i.m.) injection

• Glucagon, for i.m. injection of 1 mg• Glyceryl trinitrate (GTN) • Oral glucose /dextrose

• Oxygen • Salbutamol inhaler, 100 µg per actuation• Chlorphenamine• Parenteral midazolam /diazepam• Aspirin, 300-mg dispersible tablets• Morphine• Ammonia tabs

Anaphylaxis Anaphylaxis

Managementin severe cases

Call for an ambulance.

Secure the patient’s airway and help to restore their blood pressure by laying the patient flat and raising their feet.

Administer adrenaline, 0.5 ml (1:1000), i.m. injection repeated after 5 minutes if needed

Administer 100% oxygen – flow rate:10 litres/minute.

Call for an ambulance.

Secure the patient’s airway and help to restore their blood pressure by laying the patient flat and raising their feet.

Administer adrenaline, 0.5 ml (1:1000), i.m. injection repeated after 5 minutes if needed

Administer 100% oxygen – flow rate:10 litres/minute.

For milder forms of allergy:

Administer 1 chlorphenamine tablet,4 mg.(cadistin)

For children:Chlorphenamine Tablet, 4 mg or Oral Solution, 2 mg/5 ml

Chlorphenamine can cause drowsiness. Advise patients not to drive.

For milder forms of allergy:

Administer 1 chlorphenamine tablet,4 mg.(cadistin)

For children:Chlorphenamine Tablet, 4 mg or Oral Solution, 2 mg/5 ml

Chlorphenamine can cause drowsiness. Advise patients not to drive.

Asthma

• Salbutamol 4 puffs (if patients own puff available)

• Salbutamol 5 mg +ipratropium bromide 5OOumg nebulised

• Oxygen 10 l/min • Hydrocortisone 100 mg iv• Ventilation if needed

Angina

Signs and symptoms include:

• Chest pain• Shortness of breath• Fast and slow heart rates• Increased respiratory rate• Low blood pressure• Poor peripheral perfusion

management• Administer glyceryl

trinitrate (GTN) dispersible tab

• Administer 100% oxygen – flow rate 10 litres/minute.

• If the patient suffers more-severe attacks of chest pain or if there are sudden alterations in the patient’s heart rate, call for an ambulance.

Cardiac Arrest

Signs and symptoms include:

• Loss of consciousness• Loss of pulse and blood

pressure• Absence of breathing

management• Call for an ambulance.• Adrenaline 1 mg and repeated

after 3 – 5 mins • 2 nd dose of adr +atropine 1 mg

iv + • Initiate CPR, using 100% oxygen

for ventilation – flow rate: 10 litres/minute.

Myocardial Infarction

Signs and symptoms include:

• Progressive onset of severe, crushing pain in the centre and across the front of chest; the pain might radiate to the shoulders and down the arms (more commonly the left), into the neck and jaw or through to the back

• Skin becomes pale and clammy• Nausea and vomiting are common• Pulse might be weak and blood

pressure might fall• Shortness of breath

• Call for an ambulance and allow the patient to rest in a comfortable position.

• Administer 100% oxygen – flow rate:10 litres/minute.

• Administer GTN 1 tab sublingually• Administer aspirin, 300-mg

dispersible tablet, orally.• Morphine 5 mg imFor children:• Do not use in children because,

rarely, it can cause Reye’s syndrome

Epilepsy

Signs and symptoms include:

• Brief warning or ‘aura’• Sudden loss of consciousness, the

patient becomes rigid, falls, might give a cry and becomes cyanosed (tonic phase)

• After a few seconds, there are jerking movements of the limbs; the tongue might be bitten (clonic phase)

• There might be frothing from the mouth and urinary incontinence

• The seizure typically lasts a few minutes; the patient might then become floppy but remain unconscious

• After a variable time the patient regains consciousness but might remain confused

Management• Do not try to restrain

convulsive movements.• Ensure the patient is not at

risk from injury.• Administer 100% O2– flow

rate10 litres/minute.• If the epileptic fit is repeated

or prolonged (5 minutes or longer), continue administering oxygen and:

• Administ er diazepam 10 mg im

Faint

Signs and symptoms include:

• Patient feels faint, dizzy, light-headed

• Slow pulse rate• Low blood pressure• Pallor and sweating• Nausea and vomiting• Loss of consciousness

Management• Lay the patient flat and, if

the patient is not breathless, raise the patient’s feet. Loosen any tight clothing around the neck.

• Administer 100% oxygen – flow rate:10 litres/minute until consciousness is regained.

• Ammonia tabs crushed and sniffed to the patients

•If the patient remains conscious and cooperative administer oral glucose (10–20 g), repeated, if necessary, after 10–15 mins

•If the patient is unconscious

administer glucagon, 1 mg, i.m. injectionFor children:•Glucagon, i.m. injection•2–18 year body-weight <25 kg ……..0.5 mg•2–18 years body-weight >25 kg……..1 mg

•administer oral glucose (10–20 g) when the patient regains consciousness

•If the patient does not respond or any difficulty is experienced, call for an ambulance.

anxietyappropriate regimen to produce mild sedation to aid

anxiety management is:

• Diazepam Tablets, 5 mg, 1 tablet on night before procedure and 1 tablet 2 hours before procedure

• Advise all patients that they should not to drive.

Antiboiticsand infections

• Localized Infection, Non-allergy Patients: penicillin and amoxicillin continue to be the first drugs of choice due to their safety and effectiveness against oral infections. ions. The usual dosage is 500mg tid. .

• for the localized, non-allergy patient, the drug of choice is amoxicillin 500 mg tid If the patient does not improve after 3 days then consider "piggy-backing" the remainder of the amoxicillin with metronidazole400mg, bid. The metronidazole is effective against resistant anaerobic bacteria and works well when taken with amoxicillin.

• Spreading Infection, Non-allergy Patients: the first drug of choice is

Augmentin/clavumAmpicillin +cloxacillin(megapain)

• Spreading Infection, Allergy to Penicillin Patients: the drugs of choice are (clarithromycin) and(azithromycin) which are second generation erythromycin drugs and are effective against oral pathogens and are also broad spectrum like Augmentin. The best choice in this category is azithromycin

• Clindamycin can also be used

DENTAL PROCEDURES CONSIDERED FOR ANTIBIOTICPROPHYLAXIS IN SUSCEPTIBLE PATIENTS

High risk category• Dental extractions

• Periodontal procedures including surgery, scaling, rootplaning and probing

• Dental implant placement, reimplantation of teeth

• Endodontic instrumentation or surgery beyond the tooth apex

• Subgingival placement of antibiotic fibers or strips

• Initial placement of orthodontic bands but not brackets

• Intraligamentary local anesthetic injections

• Prophylactic cleaning of teeth or implants with andanticipated bleeding

PROCEDURES NOT RECOMMENDED FOR PROPHYLAXIS• Restorative dental procedures with

or withoutretraction cord• Local anesthetic injections (except for

intraligamentary)• Intracanal endodontic procedures, • post placement andbuildup• Placement of rubber dams• Postoperative suture removal• Placement of removable orthodontic

or prosthodonticappliances• Taking oral impressions• Fluoride treatments• Taking oral radiographs• Orthodontic appliance adjustment• Shedding of primary teeth

Cardiac conditions for prophylaxis

High risk• Prosthetic cardiac valves

• Previous bacterialendocarditis

• Complex,cyanoticcongenitalheart disease

• Surgicallyconstructed systemicpulmonary shunts

Moderate risk

• Most other congenital cardiac malformations not otherwise indicated

• Acquired valvulardysfunction

• Hypertrophiccardiomyopathy

• Mitralvalveprolapsewithregurgitation and/or thickened valve leaflets

Prophylaxis

StandardProphylaxisAmoxicillin

Adults, 2.0 grams;

Children 50 milligrams/kilogramorally one hour beforeprocedure

Cannot Use OralMedicationsAmpicillin

Adults, 2.0 g IMor IV

children, 50 mg/kgIMorIV within 30 minutesbefore procedure

Clindamycin Adults, 600 mg; children,20 mg/kg orally one hourbefore procedureCephalexin Adults, 2.0 g; children, 50 mg/kg orally one hour before procedure

Azi/clarithromycinAdults, 500 mg; children,15 mg/kg orally one hourbefore procedure

Allergic to Penicillin

ClindamycinAdults, 600 mg; children,15 mg/kg IV one hourbefore procedureCefazolinAdults, 1.0 g; children,25 mg/kg IM or IV within30 minutes before procedure

Allergic toPenicillin and Unableto Take OralMedications

Dentoalveolar abscessManagement

Local Measures – to be used in the first instance

• If pus is present in dental abscesses, drain by extraction of the tooth or through the root canals.

• If pus is present in any soft tissue, attempt to drain by incision.

Antiboitics used If drug treatment is required, an

appropriate 5-day regimen is a choice of:

Amoxicillin Capsules, 500 mg tds X 5 days

AmoxiclavMegapain

• Metronidazole Tablets, 400 mg tds X 5 days

For children:• Metronidazole Tablets,

200 mg, orOral Suspension, 200 mg/5 ml

• advise patient to avoid alcohol (metronidazole has a disulfiram-like reaction with alcohol).

• The anticoagulant effect of warfarin might be enhanced by metronidazole.

• Erythromycin is an alternative to the penicillins:Erythromycin (erythrocin) Tablets, 500mg bd X5 days

• Also clindamycin(clincin) 300 mg tid

For children:

• Erythromycin Tablets, 250 mg, or

• Oral Suspension, 125 mg/5 mldaily

• Clindamycin is not recommended for the routine treatment of oral infections because it is no more effective against anaerobes than the penicillins and can cause the serious adverse effect of antibiotic-associated colitis more frequently than other antibiotics.

• The empirical use of antibiotics, such as clindamycin, cephalosporins, co-amoxiclav or other broad-spectrum antibiotics, over amoxicillin, metronidazole and erythromycin for most dental patients can also be done

Odontogenic and space infections

The primary treatment of odontogenic infections has been surgical

Antibiotics are a necessary adjunctive therapy in many infections to hasten complete

the antibiotic must be effective against Streptococcus and anaerobes

• A. Very effective• 1. Peniccilin

– Tab clavum /augmentin– megapain

• 2. Clindamycin• 3. Metronidazole (alone or

in combination with penicillin)

• B. Effective• 1.Erythromycin/azithromyn• 2. cefexime

• Parenreral – Clavum iv od– Cefazolin iv bd– Ceftriaxone iv bd +– Metronidazole iv tid

• In the penicillin-allergic patient, clindamycin is the second drug of choice. In the penicillin-allergic patient, clindamycin is the second drug of choice.

• The first-generation cephalosporins have the same effect on the microbial population causing odontogenic infections that penicillindoes.

• The second-generation drug cefoxitin is more active against the anaerobic bacteria but loses some of the anti-streptococcal activity of the first-generation drugs.

• The third-generationcephalosporins are generally effective against anaerobes but also have increased effectivenessagainst streptococci

• Thus the second- and third-generation drugs are not highly desirable

ANUG

managementlocal Measures – to be used in

the first instance

in anug undidemeer LA-do debridement

3 % h2o2 mouthwash 2 hourly for 5 -7 days then switch to

Chx mouthwash 0.2% bd for 15 days

Medications• If drug treatment is required, an

appropriate 3-day regimen is:• Metronidazole Tablets, 400mg tid• For children:• MetronidazoleTab 400mg, or Oral Suspension, 200 mg/5 ml Or

• Amoxicillin Capsules, 500mg, or Oral Suspension 125 mg/5 ml

• Have a day gap re schedule for the treatment outcome

Sinusitis

• Local Measures – to be used in the first instance

• Advise the patient to use steam inhalation. Do not recommend the use of boiling water for steam inhalation in children.

• If drug treatment is required, an appropriate regimen is:

• Ephedrine Nasal Drops, 0.5 % 1 drop into each nostril up to three times daily when required

Advise patient to use for a maximum of 7 days. In adults and children, the dose of ephedrine nasal drops can be increased to 2 drops 3 or 4 times daily, if required.

If an antibiotic is required, an appropriate 7-day regimen is a choice of:

Amoxicillin Capsules, 500mg tdsDoxycycline Capsules, 100 mg. 2 capsules on

the first day, followed by 1 capsule daily

Pseudomembranous candidiasisLocal Measures – to be used in the first instance

• Advise patients who use a corticosteroid inhaler to rinse their mouth with water or brush their teeth immediately after using the inhaler.

• If drug treatment is required, an appropriate 7-day regimen is a choice of:

• Fluconazole Capsules, 50mg(fluzone)

• lf fluconazole and miconazole are contraindicated, an appropriate regimen is a choice of:

• Amphotericin b 10mg (fungisome). 1 lozenge dissolved slowly in the mouth after food four times daily for 10 days

Advise patient to continue use for 48 hours after lesions have healed.

• Nystatin Oral Suspension,100,000 units/ml. 1 ml after food four times daily for 7 days

Denture Stomatitis

Advise the patient to:• clean their dentures thoroughly (by

soaking in chlorhexidine mouthwash or sodium hypochlorite for 15 minutes twice daily; note that hypochlorite should only be used for acrylic dentures) and brush their palate daily to treat the condition;

• leave their dentures out as often as possible during the treatment period;

• not wear their dentures at night

If dentures themselves are identified as contributing to the problem, ensure the dentures are adjusted or new dentures are made to avoid the problem recurring.

• If drug treatment is required, an appropriate 7-day regimen is a choice of:

• Fluconazole Capsules, 150 mg per weekly

• Miconazole Oromucosal Gel24 mg/ml (daktarin)

If fluconazole andmiconazole are contraindicated, an appropriate regimen is a choice :Amphotericin Lozenges, 10 mg

• Nystatin Oral Suspension,100,000 units/ml

Angular cheilitis

• Miconazole Cream, 2% Advise patient to continue

use for 10 days after lesions have healed.

Nystatin Ointment(mycostatin)(100,000 units per g) Apply to

angles of mouth four times daily

Sodium Fusidate Ointment, 2% qid X 10 days

• An appropriate regimen for unresponsive cases is a choice of:

Hydrocortisone (1%) and Miconazole (2%) Cream bid

X 7 days

Herpetic gingivostomatitis

Aciclovir Tablets, 400 mg X 5 times /day X

For children:Aciclovir Tablets, 200 mg, orOral Suspension 200 mg/5 ml

.

Aciclovir Cream, 5% Apply to lesion every 4 hours for 5 days

Aciclovir cream can be applied for up to 10 days, if required

Penciclovir Cream, 1% Apply to lesions every 2 hours

during waking for 4 days

Varicella-zoster Infections

• In patients with herpes zoster (shingles), systemic antiviral agents reduce pain, and reduce the incidence of post-herpetic neuralgia and viral shedding

• Aciclovir is the drug of choice. However, valaciclovir and famciclovir are suitable alternatives

• Aciclovir Tab 800 mg X5/day X7 days.

Odontogenic pain• For mild to moderate

odontogenic or post-operative pain, an appropriate 5-day regimen is:

Paracetamol Tablets, 500 mg X4/day daily

• For children:

Oral Suspension 120 mg/5 ml or 250 mg/5 ml

• For mild to moderate odontogenic, post-operative or inflammatory pain, an appropriate 5-day regimen is:

Ibuprofen Tablets, 400 mg x4 /day

• For children:

• Ibuprofen Oral Suspension,100 mg/5 ml

• For mild to moderate odontogenic or inflammatory pain, an appropriate 5-day regimen is:ipobrufin +pcm(flexon)

• Or ketorolac 10 mg tid

• For moderate to severe inflammatory or post-operative pain, an appropriate 5-day regimen is:

• Codep(codine +pcm) tid

• Diclofenac Tablets, 75 mg three times daily

• Tramadol 50 mg tid

Trigeminal neuralgia• If a patient with

trigeminal neuralgia presents in primary care, control quickly by treatment with carbamazepine(tegretal)

• Carbamazepine Tablets, 200 mg bd x10 days(tegretal) can be increased to 600 mg bd

• Baclofen 5 mg tid for 3 days and increased up to 10 mg tid for 3 days

• Phenytoin 300 -600 mg bd

• Gabapentin and oxycarbamazepine can also be prescribed

• LA injections at pain sites

MPDSPharmacotherapy

•Ibuprofen400mgtd+diazepam 10 mg bd

•Naproxen 500 mg bd or celecoxib 100 mg bd

•Amytryptaline 10 mg od(triad)

•Chlorzoxazone 500 mg tid(lorzone)• tizanidine 2 mg tds •Chymoral forte qid•Pepsa 10 mg tid x 5 days

50 % of patients get relieved by this treatment

Psychological counsellingTrigger point injections

0.5 -1 ml of LA injection covering the conical area around the trigger zone(0.5 ml of procaine or 1 ml of lignocaine)

Botulism toxin patch or injection(botox)Capsaicin patch

0.025%-0.075% usedIt it’s a substance p depleter so there is decreased nerve sensitisationUsed 4 times a day for atleast 2 weeks

Oral ulcers

Causes of mouth ulcers.● Local causes:– trauma– burns● Drugs● Recurrent aphthous stomatitis● Malignant ulcers● Systemic disease:–blood disorders– gastrointestinal disorders–mucocutaneous disease– connective tissue disease– vasculitides–infective diseases● Others

• Lichen planus• Kenakort topical • Tacrolimus 0.003%

topical• Careage –

multivitamin• lycostar-antioxidant• If large lichen ulcer …

prescribe 20 mg tds x 5 days later tapered to 20 mg bd and then 10 mg bd and 5 mg bd and 5 mg od x 5 days prednisolone

Mouth ulcerations-overall management

• Local Measures – to be used in the first instance

• Antimicrobial Mouthwashes Chlorhexidine Mouthwash, 0.2% 1 minute with10 ml twice daily

• Hydrogen Peroxide Mouthwash, 6% Rinse mouth for 2 minutes with 15 ml diluted in half a glass of warm water three times daily

• Tetracycline mouthwash (now using doxycycline) is effective in some patients with recurrent aphthous stomatitis.

Local Analgesics• Lidocaine 5% ointment can be

applied to the ulcer

Benzydamine Mouthwash, 0.15% 2 hourly as required

Advise patient that benzydamine mouthwash can be diluted with an equal volume of water if stinging occurs.

• Advise patient to spit out mouthwash after rinsing.

• The mouthwash is usually given for not more than 7 days.

• Betamethasone Soluble Tab,500 umg 1 tablet dissolved in 20 ml water as a

Triamcinolone ointment_ Apply a thin layer to dried mucosa four times daily

Systemic corticosteroids in cases of immune mediated mucocutaneous ulcerations

Management of traumatic ulcers

•Remove aetiological factors and prescribe a chlorhexidine 0.2% mouthwash.

•Maintenance of good oral hygiene and the use of benzydamine (absorb)(tantum)or hot saline mouthbaths may help

•Most ulcers of local cause heal spontaneously in about 1 week if the cause is removed and suchsupportive care given.

Aphthous ulcersInformation to be given to the patients

• These are common• The cause is not known• Children may inherit ulcers from

parents• Aphthous ulcers are not thought to

be infectious• Some deficiencies or diseases may

predispose toulcers• No long-term consequences are

known• Blood tests and biopsy may be

required• Ulcers can be controlled but rarely

cured

Management of aphthae

• Any underlying predisposing factors should betreated where possible, and the aphthaecontrolled with:

• chlorhexidine 0.2% aqueous mouthwash, or

• topical corticosteroids such as hydrocortisonehemisuccinate 2.5 mg pellets, or

• 0.1% triamcinolone acetonide in Orabase usedfour times daily or

• 0.3% tricaine gel oe kenacort• in adults, tetracycline rinses 4 -5 /day

Dry mouth

Treat systemic or local disease if present

Local Measures – to be used in the first instance

• Advise the patient to take frequent sips of water

• Prilocarpine (salagen) 5 mg tid

• Saliva-stimulating Tablets (SSTs)Eg .prescription of sst like neutrasal and caphosol

OSMF

• Removal of habits is the most important factor

• Treatment is usually done with

• Hyaluronidase mixed with hydrocortisone and lignocaine and injected intralesionally

• Vit A and B and E tabs(careage)• Lycostar-antioxidant(vit A ,C ,E,

zinc ,selinium ,lycopene)

Drugs to be avoided in pregnancy

• Aminoglycosides• Tetracyclines• floroquinolones

References

• Textbook of pharmacolgy:K D .Tripathi• Emergencies in dental office:Malamed• Textbook of oral medicine:Burkit• CIMS-drugs and dosage• Journal of drugs used in dentistry:scottish