Generally, anti-hypertensive drugs, bronchodilators, anti-epileptic drugs , anti-diabetes and medications for cardiovascular diseases should be continued without alterations.
Dental patient should take usual medications, at the usual dose and at the usual time.
Patient on new generation of oral anticoagulants: rivaroxaban, dabigatran – risk of prolonged/excessive bleeding – new guidelines for invasive dental procedures (SDCEP, Scotland, August 2015)
For dabigatran New Oral Anticoagulant a reversal agent was approved in 2015 for use in the setting of urgent procedures or life-threatening bleeding
Oral premedication with eg. Temazepam should be use with caution and limitations, particularly in elderly patient (eg . agitated patients with dementia) due to unpredictable effects/reactions.
Midazolam administered intravenously may trigger an unusual reactions, opposite to sedation (‘paradoxical’), in patient with the prolonged history of drugs&alcohol misuse.
Midazolam administered intravenously should be administered with caution in young patients with diagnosed sleep apnoea.
Flumazenil (benzodiazedpine -Midazolam antagonist, emergency drug) needs to be available during IV sedation in case of adverse reactions.
Mixture of nitrous oxide and oxygen (inhalation sedation) has particularly beneficial effects in patients with severe gag reflex, anxiety and cardiological problems (eg. angina).
Combination of different NSAID with different targets points and different groups to enhance the analgesic effect: paracetamol, ibuprofen, metamizol
In patients with ‘NSAID intolerance’ due to stomach problems, it is recommended to prescribe omeprazole as a protective agent (SDCEP guideline).
Topical anaesthetic agents (gels, sprays) should be used with a caution particularly in case of large oral mucosa, exposed wounds, and in patients with poli-allergy to different chemical agents/medications, etc.
Local anaesthetic agent lidocaine should not be used in special needs patient with diagnosed congenital hypotonia (myastenia gravis).
Local anaesthetic agent articaine should not be used as a IDB local anaesthetic technique due to increased risk of prolonged lingual nerve impairment (low evidence based level though)
Local anaesthetic agent articaine with 1:100000 adrenaline addition should not be used routinely due to increased risk of unnecessary prolonged anaesthesia. Adrenaline addition 1:200000 is recommended instead.
Local anaesthetic agent articaine with 1:100 000 epinephrine should not be used as a palatal infiltration in patients receiving (or immediatelly after) radiotherapy due to increased risk of palatal bone local necrosis/demarcation (not EBD, single reports).
Local anaesthetic agents containing vasoconstrictors can be potentially contraindicated in patients with medical conditions: high blood pressure, hyperactive thyroid, unstable angina, arrhythmia, treatment with IMAO (anti-depressants)
Chlorhexidine mouthwash/gel/toothpaste may cause mouth discomfort: glossodynia (sore tongue), ‘itchy gums’ sensations, etc. in patients suffering from decreased saliva flow (dry mouth syndrome).
Chlorhexidine mouthwash 0.2 % used as a prolonged therapy may cause the extrinsic staining of the enamel and taste alteration (EBD).
Chlorhexidine mouthwash 0.2% should not be used for alveolar socket irrigation. Not EBD – single reports re: hypersensitivity/allergy to antiseptic mouthwash (ingredients, not confirmed reaction to active substance, ie. chlorhexidine).
Chlorhexidine mouthwash with less concentration 0.06% (daily) can be used for prolonged therapy eg. periodontitis
Chlorhexidine gel should be used separate times towards normal brushing as there is potential interaction between chlorhexidine gluconate and fluoride due to ionic properties (less antibacterial effect of chlorhexidine, atenuation)
Chlorhexidine 0.2% mouthwash (Corsodyl) not efficient for denture stomatitis. Recommended 2% ChX solution
Cefalexin – antibiotic prescribed eg. for odontogenic infections may cause a cross-allergic reactions in patients with allergy to Penicillin/Amoxicillin
Amoxicillin – in case of severe odontogenic infections (eg. celulitis), the use of Co-Amoxiclav (Amoxicilline + clavulanic acid) is more beneficial than Amoxicillin alone due to broad antibacterial spectrum.
Based on real cases observations, Co-Amoxiclav may cause more severe gastro-intestinal side effects compared to amoxicillin alone.
Tetracycline-based antibiotics are indicated for a long-term treatment of chronic, advanced, generalized periodontitis (EBD).
Amoxicillin – the most commonly reported adverse effect is related to skin rash. This must be differentiated with ‘true’ allergic reaction.
Avoid erythromycin, metronidazole and tetracyclines in persons with alcohol dependence (liver malfunction)
When patient reports allergy to penicillin/amoxicillin, the alternative antibiotic should be: rovamycine or metronidazole. In case of severe, resistant to standard antibiotics and spreading odontogenic inflammations of the face&neck (cellutitis), clindamycin may be considered as a second choice antibiotic after careful considerations/contraindications.
Erythromycin is usually less efficient in the treatment of odontogenic infections. Clarithromycin (on BNF since 2013), a new generation of macrolides antibiotics, seems to be more effective.
Based on real case experience, Erythromycin in adult patient may be a causative factor of severe gastro-intestinal side effects, mainly diarrhoea. It is essential to provide the adequate information including potential side effects and precautions.
Metronidazole interacts with contraseptive pills and alcohol. Patient should not be consumed alcohol while taking Metronidazole and two days after.
Clindamycin 150mg, newly introduced into BNF Dental may be useful for severe, quickly spreading odontogenic infections in patients allergic to penicillin/amoxicillin. Caution re: gastrointestinal problems, risk of colitis !
Clindamycin 150mg can be an alternative to amoxicillin in case of refractory odontogenic infections (2nd choice of antibiotic).
Benzydamine hydrochloride spray (Difflam) seems to be an efficient agent against mild oral mucosa problems (ulcerations, lacerations)
Topical corticosteroids, eg. beclometasone spray an be used off label (not licensed for oral use) in case of severe mouth ulcerations, if clinically justified.
Antifungal medications prescribed for denture stomatitis problems (eg. Miconazole oromucosal gel) – mainly palate and upper alveolar ridges – should be also used by application on upper dentures fitting surface for 7 days.
Topical Miconazole should not be prescribed for patients taking warfarin or statins due to interactions as is absorbed through topical therapy. Miconazole may enhance the effect of cumarin anticolagulant warfarin – risk of internal bleeding!
If miconazole contraindicated for denture-induced stomatitis – Nystatin 100000 IU/L oral suspension recommended
In case of angular cheilitis, Miconazole cream 2% is effective against both Candida and Gram(+) bacteria.
Interactions between some antibiotics and contraceptive pills.
Toothpaste with sodium laurate (sodium lauryl sulfate) may be an causative factor of aphthous mucosa lesions (EBD reports)
Saliva substitute (artificial saliva) in a gel seems to be more efficient in oral mucosa moisturizing than spray form (patient experience and observations).
Patient on semi synthetic opioid derivative of thebaine – buprenorphine, sublingually, for many years. Recently patient experienced painful mouth sensations. No obvious findings intraorally or changes of mouth floor which looks healthy. Is there a good idea to replace sublingual tablets with ‘patches’?
Anti-epileptic drug clonazepam may cause sialorrhoea.
Antagonism between chlorhexidine and fluoride – use CHX mouthwash at least 30 mints after teeth brushing
Avoid prescribing NSAIDs drugs (ibupofen, nurofen) in patients with asthma. They my exacerbate asthma symptoms
beta-blockers can be prescribed for patients with chronic migraine headache, resiliant to other medications, esp. in young persons (teenagers)
Prolonged use of anti-epileptic drugs can result in decreased bone density.
Carbamazepine use may affect a bone healing proces following extraction.
Phenytoine and some anti-hypertensive meds give gingival overgrowth
Fluoride varnish (eg. Duraphat) needs to applied in children with caution, particularly in case of confirmed asthma or allergy to colophony or shellac
CPP-ACP (ToothMousse) remineralising agent can be useful for the treatment of dentin hypersensitivity, acute, initial carious and erosive lesion.
Propofol used during GA introduction procedure contains ingredients which may trigger allergic reaction in people with allergy to eggs, soy and peanuts.
Regular check of emergency drugs kit (check-list)
Olanzapine (antipsychotic medication) may interact with local anaesthetics
Patients with autoimmune disease may need increased (eg. double dose) of steroids prior to invasive dental procedures
Changes in midazolam off-licence prescription since 2015
Be aware – bio-availability of oral midazolam is highly variable (25-50%)
LA with fenylpressine for pregnant patient may increase the risk of premature birth
Is 4% prilocaine with fenylpressine (Citanest) really recommended for patients with cardiological problems ?
In case when 4% prilocaine is unavailable, what kind LA is ‘safer” to use for patients with cardiological problems (angina, HBP) ? 2% Lidocaine with epinephrine 1:80000 or 4% Articaine with epinephrine 1:200000 ?
4% prilocaine with fenylpressine (Citanest) is contraindicated in pregnancy, particularly in 3rd trimester. It is believed, it may trigger muscles constrictions.
Is mepivacaine 3% ‘plain’ efficient for IDB block ?
Mepivacaine (eg. brand name Scandonest plain 3%, without vasoconstrictor is listed as class B drug. Shall we use it for pregnant patient ?
Benzocaine topical gel safer than lidocaine gel – no absorption via oral mucosa
Is there any sound evidence explaining lack of recommendation for the use articaine for IANB ?
Administration of different local anaesthetics (eg. lidocaine and articaine) into the same location is not advisable due to potential, unpredictable side effects.
Intraligamentary LA for lower premolars in phobic young patiens due to eg. orthodontic reason works very well in vast majority of cases. Uncomfortable IDB can be avoided.
Persons with Ehlers-Danlos Syndrome may report ‘insensitivity’ to local anaesthetics lack of effectiveness of LA.
Higher risk of methemoglobinemia caused by overdose of Citanest 4% prilocaine compared to lidocaine, articaine or mepivacaine.
An evidence that up to 2 cartridges of local anaesthetic containing 1:80000 adrenaline has a little effect on blood pressure in patients taking beta-blokers and diuretics
Antihypertensive medications may have an impact on dental patient’s condition during dental treatment.
There is the risk of interaction between some of antihypertensive drugs: ACE inhibitors, calcium channel blockers, beta-blokers and NSAIDs (Ibuprom) with subsequent potential reduction of antihypertensive effect
NSAIDs (Ibuprofen, Nurofen) are not indicated in patients with asthma
Oraverse (Phentolamine mesylate) non-specific reversal agent for local anaesthetic agents with adrenaline. Useful for eg. patients with special needs and risk of lip/cheek biting following LA
Diuretics may potentially cause xerostimia
Beta-blokers (propranolol) may potentially cause dry mouth, lichenoid reaction
Beta-blockers increase the toxicity of amide local anaesthetics (lidocaine)
Lidocaine can increase the myocardial depression of the beta-blockers
Calcium channel blockers (amlodypine, verapamil) may be a causative factors of gingival hypertrophy, gingival hyperplasia (overgrowth) – similar fashion to phenytoin (antiepileptic drug) and cyclosporine (immunosupressive drug)
Corticosteroids inhalers used due to asthma or COPD increase risk of denture induced stomatitis and angular cheilitis. Child on steroids inhalers – risk of angular cheilitis
Some antihypertensive drugs can induce nausea, vomiting and stimulate excessive gag reflex
Hyoscine/Scopoderm patches (attached behind ear) used to be commonly used for hypersalivation (and drooling) control, often in patients with learning disabilities
Patients who undergone breast cancer treratment can be on prolonged IV bisphosphonates therapy. Much more increased risk of ONJ compared to oral bisphosphonates
Simple thermometer can be used to check body temperature in case of dental infection. Increased temperature (pyrexia) – justification for antibiotic prescription (RCS, England)
Antimicrobial Prescribing for General Dental Practitioners (FGDP, UK):
http://www.fgdp.org.uk/content/publications/antimicrobial-prescribing-for-general-dental-pract.ashx
Drug Prescribing for Dentistry (SCDEP, Scotland):
http://www.sdcep.org.uk/published-guidance/drug-prescribing/
