13 Therapeutics

pharmaceutical name.

trade name.

Depending on patents, a generic drug may have more than one proprietary name.

The following topic is a brief guide to the clinical use of some of the more commonly used and useful drugs in hospital and general dental practice. Doses are for healthy adults. (See Table 13.1 for abbreviations.)

Extremely useful information is available in the BNF, which is updated every 6 months. Use this as the first line of enquiry when unsure about any topic concerning drugs. Drugs listed in the DPF (found at the back of the BNF) can be prescribed in the UK within the NHS on form FP10 D (GP14 in Scotland, WP10 D in Wales, HS47 in Northern Ireland). Any other required drugs must be prescribed privately or via the patient’s GMP. Many are available more cheaply OTC at pharmacies.

The BNF is the definitive reference and should always be available for consultation. Use this to check dose alterations in children (BNF for Children) and the elderly, and for more detailed tables of drug interactions, C/I, and unwanted effects. Any drug in the hospital pharmacy may be prescribed by a hospital dentist for in-patients, patients being discharged, and out-patients. The only exception is controlled drugs for those with dependency, which must be prescribed by specially licensed doctors, usually a psychiatrist.

In hospitals, there are three methods of prescribing: (i) a hospital prescription chart recording both prescriptions and dispensing, kept on the ward for in-patients; (ii) a take-home prescription form redeemable only at the hospital pharmacy for patients being discharged from the ward; (iii) hospital out-patient prescriptions, used in emergency departments and some out-patient clinics, redeemable at outside pharmacies.

Avoid abbreviations and write drug names legibly, using the generic whenever possible. Always describe the strength and quantity to be dispensed. When describing doses, use the units micrograms, milligrams, or millilitres when possible. Do not abbreviate the term microgram or unit (when prescribing insulin) as these are easily misinterpreted.

Each prescription must show: the name and address of the patient, the form, strength, dose, and total quantity of the drug to be dispensed, in both words and figures. When writing in general practice the prescription must also incorporate the phrase ‘for dental treatment only’.

Doses may need adjustment and are often substantially lower than for adults (often 50% lower).

Children differ markedly from adults in their response to drugs, especially in the neonatal period when all doses should be calculated in relation to body weight. Older children can usually be prescribed for in age ranges, usually up to 1yr, 1–6yrs, and 6–12yrs. All details of dosages should be checked in the BNF or BNF for Children.

( Hepatic disease, p. 514.) As most drugs rely on hepatic metabolism, it is prudent to seek medical advice before prescribing for patients with severe liver disease.

( Renal disorders, p. 516.) Doses almost always need to be ↓ and some drugs are C/I completely. Medical advice should be sought.

( Endocrine-related problems, p. 520.) Avoid if possible.

See Pain control in terminal disease, p. 564.

Consult BNF for dosages in children. See also Prescribing for children, p. 576. Most dental pain is inflammatory in origin and hence most responsive to drugs with an anti-inflammatory component, e.g. aspirin and the NSAIDs.

Of the peripherally acting analgesics in the DPF, aspirin, paracetamol, and ibuprofen are available cheaper direct to the public from pharmacies.

Used in mild to moderate pain, it is also a potent antipyretic, which should not be used in children <12yrs (due to the rare but serious risk of Reye syndrome). Avoid in bleeding diathesis, gastrointestinal ulceration, and concurrent anticoagulant therapy. Ask about aspirin allergy, particularly in asthmatics. Often causes transient gut irritation (as do all NSAIDs). Dose: 600–900mg 4-hourly PO. Topical salicylate gels are now C/I in <16s.

Popularly used for mild to moderate pain; has a moderate antipyretic action. Risks and side effects are similar to those of aspirin but less irritant to the gut. Dose: 400–600mg 8-hourly PO.

Similar in analgesic efficacy to aspirin but has no anti-inflammatory action and is a moderate antipyretic. Does not cause gastric irritation or interfere with bleeding times. Overdosage can lead to liver failure. Dose: 1000mg 6-hourly PO (maximum dose 4g/24h in adults).

The addition of codeine to the minor analgesics, while never being proven to be of advantage, may have marginal benefits in some cases. No combination analgesics are currently prescribable on the DPF.

There are very few indications for the use of opioid analgesics in general dental practice. Although dihydrocodeine remains in the DPF it has been demonstrated to be hyperalgesic in certain types of dental pain.¹

( Carbamazepine, p. 598.) Prescribable in the DPF.

NB While all NSAIDs may exacerbate asthma and there is a higher incidence of NSAID allergy in asthmatics, the CSM recognizes that this does not constitute a C/I for the use of these valuable analgesics. Frank allergy to NSAIDs or proven exacerbation of asthma is a C/I.

In addition to those available in the DPF, some drugs available only within hospitals are of considerable value.

is available in tablet, IM injection, suppository, and in once-daily, slow-release form. It is a mid-potency NSAID, and a useful alternative to high-dose lower potency NSAIDs or an opioid which has no anti-inflammatory effect. Dose for tablets: 50mg tds after food; IM injection: 75mg bd for no more than 2 days (it’s a painful injection); suppositories: 100mg PR od. Soluble tablets are available. Naproxen is being recommended as a less cardiotoxic alternative but has no soluble equivalent.

30mg/mL injection has advantage of small volume of injection. However, ↑ unwanted effects have been noted and it is no longer recommended for general use.

The opioids act centrally to alter the perception of pain, but have no anti-inflammatory properties. They are of value for severe pain of visceral origin, post-op (acting partly by sedation), and in terminal care. However, they all depress respiratory function and interfere with the pupillary response, and are C/I in head injury. All opioids cause cough suppression, urinary retention, nausea, constipation by a ↓ in gut motility, and tolerance and dependence. The risk of addiction is, however, greatly overstated when these drugs are used for short-term post-op analgesia and in the terminal care context. Fear of creating drug dependence should never cause you to withhold adequate analgesia.

A moderate opioid analgesic useful for short-term analgesia and less likely to mask a head injury; 30–60mg 4-hourly PO. (Rarely IM as this is a controlled form.) May be some advantage when used in combination (8/15/30mg) with simple analgesics or NSAIDs.

In oral form (tablets, elixir, or slow-release tablets or capsules), the drug of choice in the management of terminal pain. Always prescribe a laxative (macrogol laxatives are popular. Lactulose (an osmotic laxative) may be preferred as it is a smaller volume to take. This can be combined with senna (a stimulant laxative): see BNF). Dose: dependent on previous analgesia, but often starts at 10mg morphine 4-hourly or 30mg slow-release morphine sulfate bd. When used IM or IV for acute or post-op pain: 10–20mg 2–4 hourly; give an antiemetic.

A mixed opium alkaloid, frequently prescribed, but appearing to have no advantage over morphine. The presence of noscapine created a C/I in women of childbearing age. Noscapine-free equivalent (Omnopon^® 10 + 20). Neither of these is in general use currently in UK.

A mixed agonist/antagonist with similar problems to pethidine and pentazocine. Unique in that it can be given sublingually. Dose: 200–400 micrograms 8-hourly. This is often used in opioid withdrawal.

A very potent opioid which should be reserved for severe pain in an in-patient setting. Like morphine it is reversed by naloxone. Dose 1–2mg IV with appropriate patient monitoring.

An opioid which acts by two central methods. Lower side effect profile. 50–100mg PO 4-hourly. Slow IV 50–100mg 4–6-hourly. Can cause nausea and vomiting, esp IV.

Chronic and post-op pain require regular, not as-required, analgesia, given in adequate amounts and within the therapeutic half-life of the drug.

A gamma-aminobutyric acid analogue was developed for use in treatment of epilepsy. Stabilizes nerve cell membranes. It is also licensed for use in neuropathic pain in adults. 300mg PO once daily increased to twice daily then three times daily. Subsequent increases in dose may be required to a maximum of 3.6g a day.

Was designed as a more potent successor to gabapentin. Also intended as an anticonvulsant it is used for treatment of neuropathic pain and in generalized anxiety disorder. 150mg in 2–3 divided doses, increased to a maximum of 600mg daily. There is some potential for abuse and pregabalin is a controlled drug in the US.

( Patient-controlled analgesia, p. 565.) A computerized system for post-op pain control allowing patients to deliver small regular doses of IV/SC morphine/diamorphine. Gold standard post-op analgesia for severe pain.

These are among the groups of drugs that may be either analgesics or co-analgesics (drugs which are not analgesic in themselves but may aid pain relief either directly or indirectly). The two major groups are the NSAIDs ( Analgesics in general dental practice, p. 578) and the corticosteroids.

Steroids are used in various forms, topical, oral, intralesional, and parenteral, and all have uses in dentistry.

2.5mg lozenges dissolved in the mouth qds.

A topically active NSAID. Used as spray or mouthwash to ↓ pain from inflammatory mucosal conditions.

Prepared as a 0.5mg soluble tablet made into a 1mg in 10mL mouthwash rinsed qds, or a betamethasone inhaler designed for use in asthma, but can be used to spray on aphthae (1 spray = 100 micrograms). Repeatable to a maximum of 800 micrograms. Currently difficult to obtain in the UK, prednisolone dispersible tablets 5mg are a poor alternative.

Ointment is useful Rx for aphthae and related conditions seen in hospital. Hydrocortisone 1% cream is also available with miconazole 2% in DPF.

1mL (40mg) injected into lesion. Needs LA. Used in granulomatous cheilitis, intractable lichen planus, keloid scars, and painful postsurgical trigger spots.

These can be used to induce a chemical arthroplasty in arthrosis of the TMJ ( Surgery and the temporomandibular joint, p. 480).

5–10mg single injection.

(40mg/mL) can be used intra-articularly.

Main indication is prophylaxis in those with actual or potential adrenocortical suppression. Occasionally used in erosive lichen planus, severe aphthae, e.g. Behçet’s disease ( Behçet’s disease, p. 416) or arteritis ( Connective tissue diseases, p. 522).

used for prophylaxis; dose 100mg IM 30min pre-op. Doubts exist about the need for this unless the patient has demonstrated adrenocortical insufficiency (short Synacthen® test).

10–20mg PO as enteric-coated tablets given with food. Regimen dependent on the condition treated.

40mg/mL. Various regimens described for control of oedema, post major surgery.

4mg/mL. Various regimens described for control of oedema, post surgery.

are sometimes used in specialist centres. Topical tacrolimus in carboxymethylcellulose base is used for erosive lichen planus.

Another group of drugs which can be used as co-analgesics. In conditions such as atypical facial pain they may be used as the sole ‘analgesic’. However, there are no antidepressants prescribable in the DPF.

In the past, there has been considerable debate about the potential interactions between the commonest antidepressants, the tricyclics, and the monoamine oxidase inhibitors (MAOIs), and adrenaline contained in LA (which constitutes the most commonly professionally administered drug anywhere). To date, there is no clinical evidence of dangerous interactions between the adrenaline in LA preparations commonly used in dentistry and the tricyclics or the MAOIs.² In hospital practice, the two most commonly used antidepressants are amitriptyline (a sedative tricyclic antidepressant) and dosulepin (a related compound).

Use with caution in patients with cardiac disease (as arrhythmias may follow the use of tricyclics) and avoid in diabetics, epileptics, and pregnant or breast-feeding women. It can precipitate glaucoma, ↑ the effect of alcohol, and cause drowsiness (which can impair driving). In common with other tricyclics it can cause sedation, blurred vision, xerostomia, constipation, nausea, and difficulty with micturition, although tolerance to these side effects tends to develop as Rx progresses. There is often an interval of 2–4 weeks before these drugs reach a level that exhibits a clinically evident antidepressant effect. Dose: 50–75mg either as a single dose nocte or in divided doses, maximum 150–200mg daily. Children and elderly, half-dose.

has similar properties and unwanted effects to amitriptyline. It has, however, been demonstrated to be of value in the Rx of ‘facial arthromyalgia’ (a composite group of TMPDS and atypical facial-pain patients).³  Dose: initially 75mg nocte, increasing to 150mg daily if needed. Half-dose in elderly.

A less sedating tricyclic. Dose: 10–30mg nocte; can be increased.

A MAOI that may be of value in treating facial pain unresponsive to tricyclics. Dose: 10mg tds before 16.00 hours.⁴

MAOIs can precipitate a hypertensive crisis induced by dietary and drug interactions (sympathomimetics, opioids, especially pethidine, and foods containing tyramine, e.g. cheese, meat, or yeast extracts). LA is, however, safe.

Much less-sedative antidepressants, given as single dose mane. Fluoxetine is best known (20mg daily) and also abused (overprescribing and used to prolong effects of MDMA or Ecstasy Ecstasy, p. 767). Paroxetine 20mg mane, sertraline 50mg mane, and citalopram 20 mg mane (available as oral drops—8mg/4 drops = 10mg tablet) are similar.

There are no antiemetics prescribable in the DPF; however, they form an essential part of in-patient hospital prescribing. The common indication is the control of post-op nausea and vomiting, which may be due to the procedure, anaesthetic, post-op analgesia, or blood in the stomach.

A phenothiazine antiemetic which acts as a dopamine antagonist and acts at the chemoreceptor trigger zone. Avoid in small children as the drug’s major side effect, the production of extrapyramidal symptoms, is especially common in this group. Dose: 12.5mg IM 8-hourly, 20mg initially followed by 10mg tds PO. Buccal absorption 3–6mg bd. Not licensed for IV use.

has both peripheral and central modes of action. It ↑ gut motility, thus emptying the stomach. Acute dystonic reactions may occur, especially in young women and children; a bizarre acute trismus is sometimes seen as one of the manifestations. Dose: 10mg tds PO, 10mg IM 8-hourly. High-dose intermittent and continuous IV regimens are used for antiemesis in centres using cytotoxic chemotherapy.

is less likely to cause central unwanted effects such as sedation and dystonia, as it does not cross the blood–brain barrier. Acts on the chemoreceptor trigger zone and is particularly useful for chemotherapy patients. Dose: 10mg 4 hourly. May be used as part of a combination regimen, e.g. domperidone, prednisolone, and nabilone (a synthetic cannabinoid).

A selective 5-HT₃ receptor antagonist very effective in prevention and Rx of post-op nausea and vomiting. Dose: 4mg single IV dose or 8mg PO. Granisetron and tropisetron are similar 5-HT₃ receptor antagonists.

Hyoscine, antihistamines, and major tranquillizers all have antiemetic properties but are rarely indicated. If unable to control emesis with one agent use two, acting at separate sites after excluding intestinal obstruction, e.g. due to opioid constipation.

is an antihistamine and is often combined with opioid preparations as an antiemetic—however, it can aggravate heart failure. Cheap. Dose: 50mg tds IM or PO.

Do not forget the benefits of a nasogastric tube in preventing nausea and vomiting from a distended or irritated stomach. Constipation can also cause nausea—remember to exclude it as a cause.

The short-term control of fear and anxiety associated with dental Rx is an entirely appropriate use of the benzodiazepines. It should not be confused with the long-term control of anxiety which is rife with problems of dependence and drug withdrawal. A benzodiazepine may also be a valuable adjunct in the management of TMPDS, where it acts as both a muscle relaxant and an anxiolytic ( Temporomandibular pain—dysfunction/facial arthromyalgia, p. 458). IV and oral sedative techniques prior to surgery Benzodiazepines—techniques, p. 616.

Has long half-life and is cumulative on repeated dosing. Like all benzodiazepines, can cause respiratory depression, therefore patients should be warned not to drive or operate machinery while on this drug. Dose for anxiety/TMPDS: 2mg tds, maximum 30mg in divided daily doses. Paradoxical disinhibition may occur in children and its use in the <16s is not advised. Diazepam in lipid emulsion (Diazemuls^®) has traditionally been used in status epilepticus ( Fits, p. 546). A rectal preparation is popular for paediatric sedation in some countries ( Certain drugs interact, p. 614). IV lorazepam (4mg repeated after 10min if required) is popular now as this is less irritant to veins.

Water-soluble benzodiazepine of about double the potency of diazepam. Its main use is in IV sedation ( Midazolam, p. 616). Midazolam may be given in an oromucosal solution form (or the IV preparation) by buccal topical administration. This is the recommended drug for treatment of status epilepticus by dental surgeons. Also popular as a paediatric sedative for suture removal.

A long-acting hypnotic which tends to cause a hangover effect. Dose: 5–10mg nocte.

Shorter-acting hypnotic. Dose: 10–30mg nocte. Main indication is pre-op or as pre-medication. An OP sedation technique is described Temazepam, p. 616. Gelatin capsule preparations should no longer be used as they can be melted down for IV abuse.

The following may also be prescribed:

Sometimes used instead of diazepam in TMPDS. It has the same side effect profile. Dose: 10mg tds, ↑ to maximum of 100mg daily, in divided doses. It is drug of choice in the stabilization of alcohol-dependent patients.

Sometimes used as a pre-med by anaesthetists. Dose: 2mg nocte, 2mg 1h pre-op. Alternative to diazepam in epileptics.

A hypnotic sometimes used to ↓ severe insomnia in the elderly. Dose: 1–2 capsules nocte (each cap = 192mg). Main indication is in management of alcohol withdrawal. Regimen: day 1: 3 caps qds; day 2: 2 caps qds; day 3: 1 cap qds. Acute withdrawal is sometimes managed by IV infusion; however, this is a dangerous technique, not to be undertaken lightly.

are non-benzodiazepine hypnotics. Not licensed for long-term use, there is still potential for dependence.

Dose: 7.5mg nocte. Problems similar to benzodiazepines. May be of practical help when local policy controls use of temazepam.

10mg taken at bedtime. Should reduce dose by half in elderly. Similar short-acting effect to zopiclone.

10mg at bedtime (reduced in the elderly), is shorter acting than similar drugs.

Very useful in control of acute psychosis, in a dose of 10–20mg stat IM. Less painful than, and does the same job as, chlorpromazine, but main problem is extrapyramidal side effects.

A specific benzodiazepine reversal agent ( Flumazenil, p. 615). Dosages should be ↓ in elderly. Avoid in children.

An antihistamine; a useful sedative for children. Dose: 2–3mg/kg 1–2h pre-op.

(Chloral Elixir, paediatric) 5mL used as a sedative for removing facial sutures. Oral midazolam is an alternative.

When prescribing, consider: (i) the patient; (ii) the likely organisms; (iii) the best drug. Patients influence choice, in that they may be allergic to various drugs, have hepatic or renal impairment, be immunocompromised, be unable to swallow, be pregnant or breast-feeding, or taking an oral contraceptive; consider also age and severity of the infection. The infecting organism should ideally be isolated, cultured, and its sensitivity to antibiotics determined, but this is only feasible in hospital practice. In reality, most infections are treated blind, therefore it is essential to know the common infecting organisms in your field, and their sensitivities. You also need to know the drugs’ modes of action, absorption, unwanted effects, development of resistance, interactions, and techniques available for delivery. The best drug is the one which is safe in that patient, specific to the infecting organism, and can be given in a reliable convenient form. Remember prophylaxis ( Principles of antibiotic prophylaxis, p. 566) differs from Rx with antibiotics, and antibiotics do not replace the drainage of pus in abscesses.

Inactive orally and only used IM or IV. Dose: 600–1200mg IV/IM qds. Drug of choice in streptococcal infections. Like all penicillins is bactericidal: it interferes with cell-wall synthesis. Good tissue penetration except for CSF. Most important unwanted effect is hypersensitivity, which is usually manifested as a rash, rarely as fatal anaphylaxis. Patients allergic to one penicillin will be allergic to all; theoretically 10% will be allergic to cephalosporins as well. A history of atopy (e.g. asthma) ↑ risk.

Oral equivalent of benzylpenicillin. Dose: 250–500mg qds PO. Has a narrow spectrum, but is now largely superseded by:

Has a broad spectrum similar to ampicillin, but is better absorbed and achieves higher tissue concentrations. Dose: 250–500mg tds PO. Both ampicillin and amoxicillin cause a maculopapular rash in patients with glandular fever, lymphatic leukaemia, or possibly HIV infection (this is not true penicillin allergy). Amoxicillin was drug of choice in prophylaxis against infective endocarditis ( Principles of antibiotic prophylaxis, p. 566). May interfere with the action of oral contraceptives. All penicillins decrease excretion of methotrexate, therefore ↑ risk of toxicity.

One of a group of broad-spectrum antibiotics with a problem of ↑ bacterial resistance. It is likely to promote opportunistic infection with Candida albicans, particularly when used topically, as has been recommended for the Rx of aphthae. Other problems are the deposition of tetracyclines in growing bone and teeth, causing staining and hypoplasia (therefore avoid in children <12yrs and pregnancy) and erythema multiforme. It is also particularly likely to render the oral contraceptive ineffective. Dose: 250–500mg qds PO. Absorption inhibited by chelation with milk, etc., therefore should be taken well before food. May be of value in periodontal disease ( Chronic periodontitis, p. 202). Doxycycline 200mg day 1, then 100mg od PO and oxytetracycline 250–500mg qds PO are prescribable.

A similar spectrum to penicillin, but bacteriostatic. Active against penicillinase-producing organisms. Formerly an alternative to amoxicillin for endocarditis prophylaxis (superseded by clindamycin). Nausea is a major problem. Dose: 250–500mg qds PO/IV.

Of little value in dental practice, but cefalexin 250–500mg bd or tds PO and cefradine 250–500mg qds PO are prescribable. Clindamycin and metronidazole are also in DPF (see Antibiotics—2, p. 590).

Should be used cautiously in the management of dental infections, due to the risk of antibiotic-induced colitis. Useful in staphylococcal osteomyelitis in conjunction with metronidazole (which inhibits overgrowth with Clostridium difficile). Has replaced erythromycin for single-dose prophylaxis of infective endocarditis ( Principles of antibiotic prophylaxis, p. 566) when indicated.

An anaerobicidal drug, and as such effective in many acute dental and oral infections. Classical dose for NUG is 200mg tds PO 3 days. For other anaerobic infections is more often used as 400mg bd/tds (depending on severity) PO. Available in tablets, IV infusion, or suppository. Main problem is severe nausea and vomiting if taken in conjunction with alcohol (disulfiram reaction). Remember, it is not effective against aerobic bacteria.

In addition to the aforementioned:

A penicillin active against penicillinase-producing bacteria. Dose: 250–500mg qds PO/IV. Can be combined with ampicillin as co-fluampicil.

Is amoxicillin plus clavulanic acid. The latter destroys beta-lactamase (penicillinase) and hence widens the range of amoxicillin to include the commonest cause of resistance in infections of the head and neck. Now included in the DPF. Dose: 375mg or 625mg (same amount of clavulanic acid but double amoxicillin) tds PO or 600–1200mg tds IV. Problems as for amoxicillin.

A parenteral broad-spectrum cephalosporin often used in combination with metronidazole for surgical prophylaxis in contaminated head and neck procedures. Dose: 750–1500mg tds IV (500mg bd PO).

A bactericidal aminoglycoside antibiotic, active mainly against Gram –ve organisms. Complementary to the penicillins and available as a topical (ear use), parenteral preparation or impregnated in some temporary and resorbable implants used in surgical site infection. Major problem is dose-related ototoxicity and nephrotoxicity (monitor levels if used for >24h). Dose: up to 5mg/kg monitored use local guidelines. Endocarditis prophylaxis Principles of antibiotic prophylaxis, p. 566.

Has few indications in the head and neck which have not been replaced by trimethoprim alone (200mg bd). It is used, however, in ear, sinus, and urinary infections, but C/I in pregnancy and folate deficiency (as it is a folate antagonist).

Useful topically in bacterial conjunctivitis (0.5% eye drops, 1% eye ointment, apply 3-hourly). Systemic use is strictly limited due to toxicity. Ointment is an excellent wound dressing.

A unique bactericidal antibiotic. Two main uses are orally in the Rx of antibiotic-induced colitis (125mg qds 10 days PO), and for prophylaxis of patients at high risk from infective endocarditis ( Principles of antibiotic prophylaxis, p. 566). Ototoxic, nephrotoxic, prone to cause phlebitis at infusion sites, and makes people feel generally unwell, therefore not to be used lightly.

Similar to vancomycin. Lasts longer. Can be given IV or IM. Fewer unwanted effects and kinder on patient, but more expensive.

The main fungal pathogen in the mouth is Candida albicans ( Oral candidosis (candidiasis), p. 414).

Available as mixture. Dose: 100 000 units qds using 1mL of the mixture and holding it in the mouth before swallowing.

Useful drug, particularly in management of angular cheilitis, as it is active against streptococci, staphylococci, and Candida. Miconazole oral gel 24mg/mL is of use in chronic mucocutaneous and chronic hyperplastic candidosis. Dose: place 5–10mL in the mouth and hold near the lesions before swallowing, qds. Miconazole cream is used topically for angular cheilitis.

Available in both oral and IV formulations for severe mucosal candidosis in both normal and immunocompromised patients as a second line to topical preparations. Avoid in pregnancy. Dose: 50mg od PO 7–14 days, 200–400mg IV od. Itraconazole, posaconazole, and voriconazole are other antifungal drugs.

There are recognized potentially serious interactions between miconazole, fluconazole, and related drugs and: antibacterials, anticoagulants, antidiabetics, antiepileptics, antihistamines, anxiolytics, cisapride, ciclosporin, and theophylline. Check what your patient is currently taking. Candidal resistance to fluconazole is now recognized—get C&S if Rx not working.

Most viral infections are treated symptomatically. Herpes labialis is the viral condition most often seen and treated by dentists.

Active against herpes simplex and zoster; relatively non-toxic and can be given systemically or topically. Dose: herpes labialis: apply aciclovir cream to site of prodromal or early lesion 4-hourly for 5 days; herpetic stomatitis: 200mg (400mg in immunocompromised) PO 5 times daily for 5 days; herpes zoster: 800mg PO 5 times daily for 7 days.

as a 1% cream applied 2-hourly for 4 days is prescribable on the DPF for herpes labialis.

Regarded as being of little value nowadays, and is commercially unavailable. Other anti-herpes drugs include: famciclovir and valaciclovir (both pro-drugs). Ganciclovir Active against all herpes viruses, EBV, and CMV; however, it is very toxic and therefore has no indications in dentistry.

There is no known cure but combinations of drugs slow or even halt disease progression. It possible they can reduce viral load to ‘undetectable levels’. HAART (highly active anti-retroviral therapy) is described in Rx, p. 453. Used (unlicensed) for postexposure prophylaxis. Get immediate expert advice if in this situation. Lipodystrophy syndrome is associated with antiretroviral therapy. Inosine pranobex is licensed for use in treating mucocutaneous herpes simplex in conjunction with podophyllin. Interferon is an interesting drug, with no indications in dentistry.

Rarely used in the usual range of dental practice. Sometimes indicated in the management of allergy, especially hayfever, for pre-medication and sedation in children, occasionally as antiemetics, possibly in the management of overactive gag reflex, and as part of the emergency Rx of angio-oedema and anaphylaxis ( Anaphylactic shock and other drug reactions, p. 542). Main differences between the antihistamines are duration of action and degree of accompanying sedation and antimuscarinic effects.

A sedative antihistamine. Dose: 4mg qds PO.

Also a sedative antihistamine. Dose: 10–20mg bd/tds PO or 20–30mg nocte when used as a hypnotic. On sale to the public as a hypnotic.

The sedative effects of these drugs potentiate alcohol and ability to drive or operate machinery safely. They should be used with caution in glaucoma, prostatic hypertrophy, and epilepsy.

Although these drugs are available in the DPF, probably the most useful antihistamines are not. These include a wide range of non-sedating antihistamines; e.g. cetirizine, loratadine are available as OTC generics to the public, replacing terfenadine due to its greater unwanted effects.

A sedative antihistamine which may be of some value in the itching of uraemia, and occasionally used by anaesthetists as a pre-med in children. Adult dose: 10mg bd/tds; paediatric pre-med: 5–10mg, dependent on age.

Valuable in the management of sinusitis and particularly in the closure of oro-antral fistulae.

Produce vasoconstriction of mucosal blood vessels and ↓ the thickness of nasal mucosa, thus relieving obstruction. Avoid in patients taking MAOIs. Other problems: prolonged use leads to a rebound vasodilatation and a recurrence of nasal congestion, and long-term use results in tolerance and damage to nasal cilia. Dose: ephedrine nasal drops 0.5–1%, 1–2 drops into the relevant nostril qds for 7–10 days. For symptomatic nasal decongestion and as an adjunct to the management of oro-antral fistulae ( Oro-antral fistula, p. 396) inhalation of menthol and eucalyptus is valuable. Dose: 1 teaspoonful of menthol and eucalyptus inhalation BP is added to a pint of hot water, and the warm, moist air is inhaled with a towel over the head.

and spray 0.1% are a more potent alternative to ephedrine, but more likely to cause a rebound effect. Systemic decongestants are of dubious value and contain sympathomimetics. They do not, however, cause rebound also known as rhinitis medicamentosa. For prescribed, short-term use, thereby avoiding risk of rebound, xylometazoline or oxymetazoline are drugs of choice; spray into relevant nostril tds.

Although many patients are taking anticoagulants (aspirin, clopidogrel), warfarin is the drug which excites most concern. Although an evidence base exists suggesting that there is no significant increase in post-extraction bleeding in patients with an INR within the reference range (2–4) and many regions’ oral & maxillofacial surgery units routine practice is to perform extractions as normal for patients on warfarin with an INR of <4, some controversy still exists. BNF 63 states ‘Patients requiring minor dental procedures (including extractions) who have an INR below 4 may continue warfarin without dose adjustment’. INR should be checked within 72 hours of the procedure starting. If multiple extractions are required, then a single extraction should be carried out first. Subsequent extractions of two to three teeth at a time may be carried out if recovery is uneventful.

In general there is no greater risk if performing small numbers of extractions in patients anticoagulated with warfarin if the INR <4. Local measures such as packing the socket with oxidized cellulose and suturing gingivae with local pressure will achieve haemostasis. Patients with an INR >4 should be referred to their anticoagulant clinic or physician. Patients requiring multiple extractions or with other significant co-morbidities should be seen in an area which can provide a higher level of care.

These are a range of drugs which act on osteoclasts and reduce the rate of bone turnover. They bind to hydroxyapatite and their effect is therefore extremely long term (possibly up to 10 years). They are an important group of drugs in the prophylaxis and treatment of osteoporosis, steroid-induced osteoporosis, Paget’s disease, bone metastases (particularly breast, myeloma and prostate), and hypercalcaemia of malignancy.

They come in differing degrees of potency, non-nitrogen containing oral preparations being the least potent and nitrogen containing IV preparations being the most. Osteoporosis tends to be managed with less potent drugs and hypercalcaemia and bone metastases with the most.

Bisphosphonate Related Osteonecrosis of the Jaws (BRON aka BRONJ aka Anti-resorptive Related Osteonecrosis of the Jaws (ARONJ) is a condition where alveolar bone is exposed in the mouth in patients taking these drugs. The condition appears to be progressive and there is no established effective treatment although several are being investigated. Bone necrosis without mucosal beach is also described. The incidence is variable but is probably much less than 1% for patients treated with low potency drugs for osteoporosis up to 30% for myeloma survivors at 10 years who have received highly potent drugs and who have had extractions.

Prevention is the most useful management strategy and all patients prior to starting bisphosphonates should have optimum dental health established such that it is highly unlikely they will ever need to have a tooth removed in the future. This is a shift away from the ‘benefit of the doubt’ approach most dentists are currently trained in. The nearest comparable approach is in the prevention of osteoradionecrosis.

Management of established BRON Treatment of established BRON, p. 364 (see Table 13.2).

Denosumab is a human monoclonal antibody that inhibits osteoclast formation, function, and survival. It is used in the treatment of osteoporosis, bone metastasis, and a number of other conditions that result in ↑ bone turnover. It is only available in IV form and is considered a million times more potent than etidronate. Denosumab and other non-bisphosphonate drugs still have the potential to cause bone necrosis.

A number of drugs not fitting into any specific category are important in managing oral and dental disease. These include:

Primarily an antiepileptic drug which is of considerable value in the management of trigeminal and glosso-pharyngeal neuralgia. C/I in those sensitive to the drug, patients with atrioventricular conduction defects, porphyria, and should be used with extreme caution in patients on MAOIs, who are pregnant, or who have liver failure. May interfere with the oral contraceptive. Common unwanted effects are gastrointestinal disturbances, dizziness, and visual disturbances. Rarely, rashes may occur, as can leukopenia. Do a FBC soon after starting carbamazepine: blood dyscrasias usually occur in the first 3 months. Dose: 100–200mg bd; can be ↑ gradually to 200mg tds/qds. Maximum 1600mg daily in divided doses. Important to be sure of your diagnosis before starting patients on long-term carbamazepine ( Facial pain, p. 438). A slow-release preparation with fewer unwanted effects is available.

There is no indication for first-line Rx with vitamins in dental practice. Deficiency due to inadequate dietary intake in the UK is exceedingly rare. Although it can occur in the elderly and alcoholics, these people should be fully investigated and not treated empirically. Severe gingival swelling, stomatitis, glossitis, or pain should be fully investigated before using vitamin supplements. The only preparations available in the DPF are:

Valuable adjunct in the management of xerostomia, especially after radiotherapy and in Sjögren syndrome. A slightly viscous, inert fluid which may have a number of additives, such as antimicrobial preservatives, fluoride, flavouring, etc. Useful preparations are Glandosane^® and Saliva Orthana^®, aerosol sprays sprayed sublingually 4–6 times per day. The latter contains fluoride. Saliva Natura^® is an ‘organic’ alternative. Regular sips of water may be of more practical long-term help. DPF has Artificial Saliva DPF 60mL unit. Use: all should be sprayed into the floor of mouth area to act as a ‘puddle’ for redistribution. Do not spray all over mucosa. Use qds. In addition, the DPF states the following may only be prescribed for patients having undergone radiotherapy or suffering from SICCA syndrome: AS Saliva Orthana^®, Glandosane^®, Biotene Extra Gel Mouthspray^®, Biotene Extra Moisturising Gel^®, Saliveze, Salivix^®.

Two main uses:

1 For preparation of a site prior to injection, e.g. of LA. Lidocaine 5% ointment or spray is the most useful. Flavoured benzocaine pastes are available in some countries (not UK).

2 EMLA® and tetracaine (Ametop^®) can be used on mucosa. Carmellose gelatin paste acting as a mechanical barrier is useful in areas where it will adhere. Many OTC agents are available; few are of great potency. To ↓ pain from minor oral lesions (e.g. for HSV 1 or aphthae). Benzydamine rinse is a mainstay.

Fluoride supplementation is discussed in Fluoride, p. 28. It is important when using rinses, and particularly gels, that the fluid is not swallowed, since there is a risk of toxicity ( Planning fluoride therapy, p. 30).

Used in some centres to manage erosive lichen planus and leucoplakia; have proved disappointing.

When prescribing any drug for patients already compromised by concomitant disease or drug therapy, it is essential to exclude possible interactions. This can be achieved fairly quickly by consulting the comprehensive BNF.

Interactions with the most commonly given drug (LA) are covered in Local analgesia—tools of the trade, p. 606.

The lists in Table 13.3 are not comprehensive and some of the drugs mentioned can be used in suitably modified dose or under specific circumstances. These tables are designed to ring alarm bells, and encourage you to both think and consult the BNF.

Almost any drug can produce these, and many are missed. Try to avoid polypharmacy, and never prescribe without being aware of a patient’s full medical history. Always enquire about drugs, including self-prescribed medication. See Table 13.4 for emergency drugs.

Report suspected adverse reactions to Medicines and Healthcare products Regulatory Agency (MHRA): email: [email protected], phone: 0800 731 6789, or in writing to:

CSM Freepost, London SW8 5BR

CSM West Midlands SW 2991, Freepost, Birmingham B18 7BR

CSM Mersey, Freepost, Liverpool L3 3AB

CSM Northern, Freepost 1085, Newcastle NE1 1BR

CSM Wales, Freepost, Cardiff CF4 1ZZ

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