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 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

Signs and symptoms include:

• Generalised itching (urticaria), • Flushing, but pallor might also

particularly of hands and feet
• Rhinitis, conjunctivitis
• Abdominal pain, vomiting,
diarrhoea, and a sense of
impending doom
occur
• Marked upper airway
(laryngeal) oedema and
bronchospasm, causing stridor
and wheezing
 Management
in 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.

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

acute severe asthma Life threatening asthma

• Inability to complete • Cyanosis or respiratory
sentences in one rate <8 per minute
breath • Bradycardia (heart rate
• Respiratory rate >25 per <50 per minute)
minute • Exhaustion, confusion,
• Tachycardia (heart rate decreased conscious
>110 per minute) level
• 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
• 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 im
For children:
• Do not use in children because,
rarely, it can cause Reye’s syndrome
 Epilepsy
Signs and symptoms include: Management
• Do not try to restrain
convulsive movements.
• Brief warning or ‘aura’ • Ensure the patient is not at
• Sudden loss of risk from injury.
consciousness, the • Administer 100% O2– flow
patient becomes rigid, rate10 litres/minute.
falls, might give a cry • If the epileptic fit is repeated
and becomes cyanosed or prolonged (5 minutes or
(tonic phase) longer), continue
• After a few seconds, administering oxygen and:
there are jerking • Administ er diazepam 10 mg
movements of the im
limbs; the tongue might

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
Faint
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
10–15 mins

•If the patient is unconscious

administer glucagon, 1 mg, i.m. injection

For 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.
 anxiety
appropriate 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.

 Antiboitics
and 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/clavum
Ampicillin +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 ANTIBIOTIC
PROPHYLAXIS 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,cyanoticcongenital
heart disease
• Surgicallyconstructed
systemicpulmonary shunts
Moderate risk
• Most other congenital cardiac
malformations not otherwise
indicated
• Acquired valvulardysfunction
• Hypertrophiccardiomyopathy
• Mitralvalveprolapsewithregurg
itation and/or thickened valve
leaflets
 Prophylaxis
Allergic to
Allergic to Penicillin Penicillin and
Clindamycin Unable
Standard Cannot Use Adults, 600 mg; to Take Oral
Prophylaxis Oral children, Medications
Amoxicillin Medications 20 mg/kg orally one
Ampicillin hour
Adults, 2.0 grams; before procedure Clindamycin
Cephalexin Adults, 600 mg;
Adults, 2.0 g
Adults, 2.0 g; children,
IMor IV
children, 15 mg/kg IV one
Children
50 mg/kg orally one
50 children, 50 hour
hour
milligrams/kilogra mg/kgIMor before procedure before
m IV within 30 procedure
Cefazolin
orally one hour minutes Azi/clarithromycin Adults, 1.0 g;
before before Adults, 500 mg; children,
procedure procedure children, 25 mg/kg IM or
15 mg/kg orally one IV within
hour
30 minutes
before procedure
before
 Dentoalveolar abscess
Management
Antiboitics used
Local Measures – to be used If drug treatment is required, an
in the first instance appropriate 5-day regimen is a
choice of:

• If pus is present in dental Amoxicillin Capsules, 500 mg tds

abscesses, drain by X 5 days
extraction of the tooth or
through the root canals. Amoxiclav
• If pus is present in any soft Megapain
tissue, attempt to drain by
incision.
 • advise patient to
• Metronidazole Tablets, avoid alcohol
400 mg tds X 5 days (metronidazole has a
For children: disulfiram-like
• Metronidazole Tablets, reaction with
200 mg, orOral alcohol).
Suspension, 200 mg/5
• The anticoagulant
ml
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
• The empirical use of
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.
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
• Parenreral
– Clavum iv od
– Cefazolin iv bd
– Ceftriaxone iv bd +
– Metronidazole iv tid

• 3. Metronidazole (alone or
in combination with
penicillin)
• B. Effective
• 1.Erythromycin/azithromyn
• 2. cefexime
 •
• In the penicillin-allergic The first-generation cephalosporins
have the same effect on the microbial
patient, clindamycin is population causing odontogenic
infections that penicillindoes.
the second drug of
• The second-generation drug cefoxitin
choice. In the penicillin- is more active against the anaerobic
bacteria but loses some of the anti-
allergic patient, streptococcal activity of the first-
clindamycin is the generation drugs.
second drug of choice. • 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
management
local 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
• If drug treatment is required, an
appropriate regimen is:

• Local • Ephedrine Nasal Drops, 0.5 % 1 drop into

each nostril up to three times daily when
Measures – to required
be used in the Advise patient to use for a maximum of 7
days. In adults and children, the dose of
first instance ephedrine nasal drops can be increased to
2 drops 3 or 4 times daily, if required.

If an antibiotic is required, an appropriate 7-

• Advise the day regimen is a choice of:
Amoxicillin Capsules, 500mg tds
patient to use Doxycycline Capsules, 100 mg. 2 capsules on
steam the first day, followed by 1 capsule daily

inhalation. Do
not
 Pseudomembranous candidiasis
Local 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
• If drug treatment is
required, an appropriate
7-day regimen is a choice
of:

• Fluconazole Capsules,
150 mg per weekly
Advise the patient to: • Miconazole Oromucosal
Gel24 mg/ml (daktarin)
• clean their dentures If fluconazole andmiconazole
thoroughly (by soaking are contraindicated, an
appropriate regimen is a
in chlorhexidine choice :Amphotericin
Lozenges, 10 mg
mouthwash or sodium • Nystatin Oral Suspension,
hypochlorite for 15 100,000 units/ml
minutes twice daily; note
that hypochlorite should
 Angular cheilitis

• Miconazole Cream, 2% • An appropriate regimen for

Advise patient to continue unresponsive cases is a
use for 10 days after lesions choice of:
have healed.
Hydrocortisone (1%) and
Nystatin Ointment(mycostatin)
Miconazole (2%) Cream bid
(100,000 units per g) Apply to
angles of mouth four times X 7 days
daily
Sodium Fusidate Ointment,
2% qid X 10 days
 Herpetic gingivostomatitis
Aciclovir Cream, 5% Apply to
Aciclovir Tablets, 400 mg X 5 times lesion every 4 hours for 5 days
/day X
Aciclovir cream can be applied
for up to 10 days, if required
For children:
Aciclovir Tablets, 200 mg, or
Penciclovir Cream, 1%
Oral Suspension 200 mg/5 ml 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 • For mild to moderate
odontogenic or post- odontogenic, post-operative or
operative pain, an inflammatory pain, an
appropriate 5-day
regimen is: appropriate 5-day regimen is:
Paracetamol Tablets, Ibuprofen Tablets, 400 mg x4 /day
500 mg X4/day daily
• For children: • For children:

Oral Suspension 120 • Ibuprofen Oral Suspension,100

mg/5 ml or 250 mg/5 mg/5 ml
ml
• For mild to • For moderate to severe
inflammatory or post-
moderate operative pain, an
odontogenic or appropriate 5-day
inflammatory pain, regimen is:
an appropriate 5-day • Codep(codine +pcm) tid
regimen is:ipobrufin
+pcm(flexon) • Diclofenac Tablets, 75 mg
three times daily
• Or ketorolac 10 mg • Tramadol 50 mg tid
tid
 Trigeminal neuralgia
• If a patient with • Baclofen 5 mg tid for 3
trigeminal neuralgia days and increased up to
presents in primary 10 mg tid for 3 days
care, control quickly • Phenytoin 300 -600 mg
by treatment with bd
carbamazepine(tegret • Gabapentin and
al) oxycarbamazepine can
• Carbamazepine also be prescribed
Tablets, 200 mg bd
x10 days(tegretal) can
be increased to 600 • LA injections at pain sites
mg bd
 MPDS
Pharmacotherapy
•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 counselling
Trigger 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% used
It it’s a substance p depleter so
there is decreased nerve
sensitisation
Used 4 times a day for atleast 2
weeks
 Oral ulcers
Causes of mouth ulcers. • Lichen planus
● Local causes:
– trauma
– burns
● Drugs
● Recurrent aphthous
stomatitis
● Malignant ulcers
● Systemic disease:
–blood disorders
– gastrointestinal
• 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 ulcers
Information 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 • Prilocarpine (salagen) 5
mg tid
Local Measures – to be
used in the first instance • Saliva-stimulating Tablets
(SSTs)Eg .prescription of
sst like neutrasal and
• Advise the patient to caphosol
take frequent sips of
water
 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