Common Prescriptions in Dentistry ANALGESICS Rx: Mitte: Sig: Tylenol #3 Daily max is based on daily maximum of acetaminophen = 4000

mg/d 30 tabs i-ii tabs q 4-6 h prn pain

Note: T#3 contains 30mg codeine & 300 mg acetaminophen Rx: Mitte: Sig: Toradol (10 mg tablets) 20 tabs i qid prn pain Adult dosages: o Oral - 20mg loading, then 10mg qid o IM - 30 mg q6h o IV - 30mg q6h o Max. adult dosages: o Oral - 40mg/day for max. of 5 days o IV/IM - 20 doses over 5 days (120mg/day) No pediatric dosage regimens established Rx: Mitte: Sig: Percocet 30 tabs i q 4-6h prn pain

Note: Percocet = 5 mg oxycodone + 325 mg acetaminophen ANTIBIOTICS Rx: Mitte: Sig: Amoxicillin (500 mg) 21 tabs i tid x 7d Daily maximum = 2 g

<40kg: 20-40mg/kg/d dose q8h x7d Rx: Mitte: Sig: Rx: Mitte: Sig: or Mitte: Sig: Rx: Mitte: Sig: Rx: Mitte: Sig: Note: Rx: Mitte: Sig: Clindamycin (300 mg) 28 capsules i q6h until finished Penicillin VK (300 mg) 56 tabs ii qid until finished 29 tabs ii stat, then I q6h x 7d Metronidazole (500 mg) 21 tabs i q 8h until finished Daily maximum = 4g Daily maximum = 1.8 mg

Daily Maximum = 3g

Chlorhexidine Gluconate (0.12% oral rinse) 475 mL rinse with 5-10 mL for 30 sec & expectorate; repeat bid; npo hour; avoid F- hr can also get Aqueous CHX (0.2%) (250 mL) for patients with xerostomia or painful oral lesions Ceftriaxone (1 g) IV 1g i q 24h

ANTIFUNGAL Rx: Nystatin oral suspension (100,000 units/mL)

Mitte: Sig:

240 mL rinse with 1 tsp qid; rinse & hold in mouth for as long as possible before swallowing or spitting out (2 minutes); npo for hour

Note: This rinse contains 50% sucrose!!! ANTIVIRAL Rx: Mitte: Sig: Rx: Mitte: Sig: Rx: Mitte: Sig: Rx: Mitte: Sig: Acyclovir (200 mg) 42 capsules i q4h for 7 days Tranexamic Acid (5%) 200 mL bottle 5 ml swish x 1min qid 24 h before appt & for 3-5 d after Tantum oral rinse (0.15%) 250 mL bottle 15 ml swish x 1-2min qid; expectorate; swish minimum of 30s; if burns while swishing, can dilute 1:1 w water Oracort (0.1%) 1 tube (5mg)

ANTI-EMETICS Rx: Mitte: Rx: Mitte: Maxeran (metoclopramide) Daily Maximum: 0.5 mg/kg 10mg IV Gravol (25-50mg) IM or PO q4h prn

CORTICOSTEROID Rx: Mitte: Decadron (dexamethasone) 6mg IV q6h x4, then 4mgPO q6h x4, then 2mgPO q6h x4, then d/c

SALIVARY STIMULANT Rx: Salagen (pilocarpine) Mitte: 5mg PO qid x 4wks. Re-evaluate. Do resting vs stimulated sliva production test to determine presence of reserve fx ULCER TREATMENT Rx: Benzydamine (0.15%) Tantum Rinse OR 2% Viscous Lidocaine + CHX be careful if numb may chew up ulcers if they cant feel them) LOCAL ANAESTHETICS Oral Midazolam: 0.5mg/kg, max 25mg Calculation of Doses % Solutions represent grams per 100 mL Move the decimal place to the right and this value = mg/mL i.e. 2% Lidocaine = 20 mg/mL Most cartridges = 1.8 mL one cartridge of 2% Lido contains 1.8 mL x 20 mg/mL = 36 mg Example: Lidocaine for a 20 kg child 7 mg/kg x 20kg = 140 mg 2% Lido = 20 mg/mL 140 mg / (20 mg/mL) = 7 ml Each cartridge = 1.8 mL 3.9 cartridges may be used

Agent Lidocaine * -xylocaine

Contents 2% + 1:100 000 epi 2% + 1:50 000 epi

Dosage w/epi = 7mg/kg 500 mg no epi = 4.5mg/kg 300 mg kids = 4.5mg/kg w/epi= 7mg/kg 500 mg kids > 4y.o. = 5mg/kg w/ levo = 6mg/kg 400mg no levo = 4.5mg/kg 400mg

Duration intmdt

Notes

Articaine -astracaine -ultracaine Mepivicaine **

4% + 1:100 000 epi 4% + 1:200 000 epi

intmdt

C/I in sulfa allergy, metHbemia

short

2% + 1:20 000 levonordephrine -isocaine -carbocaine -polocaine Prilocaine * -citanest Bupivicaine ** -sensorcaine -marcaine 3% (no vasoconstrictor) 4% + 1:200 000 epi

w/epi = 6mg/kg 400 mg no epi = 4.5mg/kg 400 mg w/ epi = 3.2mg/kg 150mg no epi = 2.5mg/kg 150mg 8mg/kg 400mg

intmdt

C/I in metHbemia Perm. neurotoxicity; No kids, handicapped, pregnant/cardiac female

0.5% + 1:200 000 epi

long

Etidocaine * 1.5% + 1:200 000 epi long -duranest 1.8 mL carpule: 1% = .01g/mL = 10 mg/mL 18mg/1.8mL 1: 100 000 = 1g/100 000mL = 1000mg/100 000mL = .01mg/mL .018mg/1.8mL LA relative C/I: Liver dysfcn (ASA III-IV) Kidney dysfcn (ASA III-IV) Epi relative C/I: Cardiovascular disease (ASA III-IV) max epi = .04 mg; max levo = .2mg Hyperthyroid (ASA III-IV) same same Healthy Patient max epi = .2 mg; max levo = 1.0 mg *, ** = allergy groups

Adverse Drug Reactions Involving Antibiotics Bacteriostatic and bactericidal combinations Tetracyclines with products containing divalent and trivalent ions dairy, antacids, vitamin preparations Mg++, Ca++, Fe++, Al++, Bi++, Zn++ impairs absorption of tetracycline from GI tract although individual tetracycline moieties can differ doxycycline and minocycline are not as affected by Ca++ and Zn++

Metronidazole Metronidazole and Alcohol (Antabuse effect) like Disulfiram (Antabuse), metronidazole has been shown to inhibit the activity of acetaldehyde dehydrogenase Accumulation of acetaldehyde in patients concomitantly using EtOH and prescribed Metronidazole. Should avoid EtOH for 3-5 days following course of metronidazole Metronidazole and Lithium concomitant use can lead to decreased renal excretion of lithium and subsequent toxicity metronidazole inhibits renal excretion of lithium supported by three documented cases in the literature Tetracyclines Tetracyclines and Lithium single case report in literature of a woman with 3 yr hx of lithium therapy on maintenance concentration, who suddenly developed s/s of Li toxicity after 1 week course of tetracyclines

questionable, also data that refutes this claim

Erythromycin/Clarithromycin or Tetracyclines In combination with cardiac glycosides (digoxin) can lead to digitalis toxicity 10% of people harbour enteric bacteria (Eubacterium lentum) that inactivate digoxin in GI these antibiotics decimate these enteric bacteria leading to marked increase in dig levels. Tetracyclines and other broad spectrum antibiotics Oral anticoagulants (warfarin, dicoumarol) function via competitive antagonism of Vit. K- dependent clotting factors (II, VII, IX, X) broad spectrum Abs (tetracycline, amoxicillin, ampicillin) can reduce endogenous Vit. K by decimating the normal gut flora that produce it in turn, this enhances the anticoagulation effect of warfarin, etc Again, this is a weak association is only of concern in patients with poor Vit. K intake 4. Macrolides or Metronidazole In combination with oral anticoagulants (warfarin) marked increase in warfarin levels, with subsequent elevation in INR and serious spontaneous bleeding risk. Definite risk and concomitant use of these agents should be avoided. Analgesics 1. NSAIDs antihypertensives Li anticoagulants methotrexate ethanol digoxin cyclosporin NSAIDS and Antihypertensives Specifically those classes of antihypertensive which depend on renal prostaglandin mechanisms ACE inhibitors Diuretics (furosemide and thiazide type) Beta blockers Note : Ca channel blockers are not implicated More of a problem for prolonged use of NSAID or in elderly or patients with low renin hypertension NSAIDs and Lithium Inhibition of renal prostaglandin = less Li excreted by kidneys thus greater risk of Li toxicity prescribe NSAIDs for people on Li for only short duration, especially if elderly NSAIDs and Warfarin Avoid altogether Rx NSAIDs (especially ASA) to people on warfarin profoundly attenuates hemostasis, potential for severe/fatal hemorrhage think about why you are using it in the first place (post-exo, perio tx) NSAIDs and Methotrexate Methotrexate is used for variety of conditions rheumatoid arthritis, psoriasis little concern with concomitant use of NSAIDs in these patients on methotrexate due to low dose. However, methotrexate is also used in chemotherapeutic management of certain cancers higher dose, coupled with the reduced renal clearance caused by NSAIDs carries a significant risk of toxicity (pancytopenia, renal failure) NSAIDs and EtOH Especially ASA, can lead to gastric bleeding if combined with EtOH in short, ASA is acidic, ethanol stimulates gastric acid, two together will potentiate ASA-induced gastric bleed.

NSAIDs and Digoxin NSAIDs can reduce renal function, thus impairing clearance of digoxin and leading to digoxin toxicity. More of a concern in elderly and in people with impaired renal function Should not be an obstacle in prescribing to people with normal renal function (unless chronic use) NSAIDs and Cyclosporin Weak link idea is sound put them together and risk of kidney damage is amplified. 2. ASA sulfonylureas (oral hypoglycemics) anticonvulsants carbonic anhydrase inhibitors 3. Acetaminophen alcohol 4. Opioids alcohol meperidine + MAO inhibitors Opioids Used in combination with EtOH will increase CNS depression Specific opioid (meperidine) and MAO inhibitors mechanism of interaction is unclear, but may be result of serotonin accumulation secondary to MAO inhibition can get variety of s/s from agitation/hypertension/seizures to respiratory depression/hypotension/coma

NSAIDs are nephrotoxic Cyclosporin is nephrotoxic Theoretically this makes sense, but not enough data to support it

Acetaminophen Mediation of hepatic toxicity is a complex interplay between CYP2E1, NAPQI and glutathione levels all of which depends on timing of EtOH abuse/cessation with initiation of acetaminophen serious risk of hepatic failure if timed properly ASA + Oral hypoglycemics Enhances hypoglycemic effect ASA enhance insulin secretion displace protein binding of sulfonylureas ASA and anticonvulsants Theoretical risk of displaced protein binding and inhibition of main metabolic pathway of valproic acid by ASA several case reports published , but weak association Dilantin may also be affected in this manner, but scant evidence to support. ASA and carbonic anhydrase inhibitors Avoid ASA in elderly patients and those with renal failure on carbonic anhydrase inhibitors may lead to excessive levels due to displacement from plasma protein binding sites and reduction in renal clearance results in lethargy, incontinence and confusion LA and opioids Particular risk in children attributable to respiratory depression induced by opioids with resulting respiratory acidosis and hypercapnia increases cerebral perfusion pressure decreases protein binding in presence of lidocaine, this will increase CNS excitation, seizures and cardiac arrest LA- induced methemoglobinemia Mainly prilocaine and benzocaine although reported cases with articaine and lidocaine

results in oxidation of iron atom within hemoglobin, producing methemoglobin can also be caused by: nitroglycerin dapsone and sulfonamide phenacetin

Methemoglobinemia risk factors Extremes of age anemia respiratory disease hereditary deficiencies in G6P dehydrogenase and methemoglobin reductase deficiencies Note: Prilocaine induced methemoglobinemia appears to be due more to total dose than presence of risk factors