Vistaril
Hydroxyzine
Common brand names: Atarax, Vistaril
Description: Hydroxyzine is an antihistamine drug that relaxes patients, induces drowsiness and prevents nausea and vomiting.
Dental uses: Hydroxyzine can be used alone in adult dental patients as a mild antianxiety agent, but its most frequent use is to sedate uncooperative pediatric dental patients when used in combination with chloral hydrate. In children, hydroxyzine increases the sedative effects of chloral hydrate while reducing that drug’s incidence of nausea and vomiting.
Dosages for dental purposes: The adult dose of hydroxyzine ranges from 25 milligrams to 100 milligrams taken one hour prior to the dental procedure. In children, hydroxyzine usually is administered as a syrup 30 minutes to one hour prior to the dental procedure, with the dose based on the child’s body weight at a dose no greater than 0.6 milligrams per kilogram (one kilogram equals 2.2 pounds).
Concerns and possible side effects: Hydroxyzine is generally a very well-tolerated drug. The most common side effects are drowsiness and a dry mouth (xerostomia). Adult patients should not operate dangerous machinery or drive automobiles for up to 24 hours after receiving hydroxyzine. In children, hydroxyzine usually will be administered in combination with chloral hydrate by a pediatric dentist. The combination tends to produce a much greater degree of drowsiness, confusion and lack of coordination than either drug alone. Therefore, following the dental procedure, children should be well supervised at home and refrain from outdoor activities for the remainder of the day.
Sildenafil
Sildenafil
Sildenafil citrate, sold under the names Viagra, Revatio and generically under various other names, is a drug used to treat male erectile dysfunction (impotence) and pulmonary arterial hypertension (PAH), developed by the pharmaceutical company Pfizer. Viagra pills are blue and diamond-shaped with the words “Pfizer” on one side, and “VGR xx” (where xx stands for “25”, “50” or “100”, the dose of that pill in milligrams) on the other. Its primary competitors on the market are tadalafil (Cialis), and vardenafil (Levitra).
Mechanism of action
Part of the physiological process of erection involves the parasympathetic nervous system causing the release of nitric oxide (NO) in the corpus cavernosum of the penis. NO binds to the receptors of the enzyme guanylate cyclase which results in increased levels of cyclic guanosine monophosphate (cGMP), leading to smooth muscle relaxation (vasodilation) in the corpus cavernosum, resulting in increased inflow of blood and an erection.
Sildenafil is a potent and selective inhibitor of cGMP specific phosphodiesterase type 5 (PDE5) which is responsible for degradation of cGMP in the corpus cavernosum. The molecular structure of sildenafil is similar to that of cGMP and acts as a competitive binding agent of PDE5 in the corpus cavernosum, resulting in more cGMP and better erections. Without sexual stimulation, and therefore lack of activation of the NO/cGMP system, sildenafil should not cause an erection. Other drugs that operate by the same mechanism include tadalafil (Cialis®) and vardenafil (Levitra®).
Sildenafil is metabolised by hepatic enzymes and excreted by both the liver and kidneys. If taken with a high-fat meal, there may be a delay in absorption of sildenafil and the peak effect might be reduced slightly as the plasma concentration will be lowered.
Dosage and price
As with all prescription drugs, proper dosage is at the discretion of a licensed medical doctor. The dose of sildenafil is 25 mg to 100 mg taken once per day between 30 minutes and 4 hours prior to sexual intercourse.
It is usually recommended to start with a dosage of 50 mg and then lower or raise the dosage as appropriate. The drug is sold in three dosages (25, 50, and 100 mg), all three costing about US$10 per pill. Name-brand Viagra sildenafil is not scored and a fairly hard coating makes it more difficult to accurately cut the pills in half, even with a pill cutter.
Contraindications
Contraindications include:
* When taking nitric oxide donors, organic nitrites and nitrates, such as glyceryl trinitrate (nitroglycerin), sodium nitroprusside, amyl nitrite (“poppers”)[5]
* In men for whom sexual intercourse is inadvisable due to cardiovascular risk factors
* Severe hepatic impairment (decreased liver function)
* Severe impairment in renal function
* Hypotension (low blood pressure)
* Recent stroke or heart attack
* Hereditary degenerative retinal disorders (including genetic disorders of retinal phosphodiesterases)
Side effects
Amongst sildenafil’s serious adverse effects are: priapism, severe hypotension, myocardial infarction, ventricular arrhythmias, sudden death, stroke and increased intraocular pressure.
Common side effects include sneezing, headache, flushing, dyspepsia, prolonged erections, palpitations and photophobia. Visual changes including blurring of vision and a curious bluish tinge have also been reported.
Care should be exercised by patients who are also taking Protease inhibitors for the treatment of HIV. Protease inhibitors inhibit the metabolism of sildenafil, effectively multiplying the plasma levels of sildenafil, increasing the incidence and severity of side-effects. It is recommended that patients using protease inhibitors limit their use of sildenafil to no more than one 25-mg dose every 48 hours.
Some sildenafil users have complained of blurriness and loss of peripheral vision. In May of 2005, the U.S. Food and Drug Administration found that sildenafil could lead to vision impairment and a number of studies have linked sildenafil use with nonarteritic anterior ischemic optic neuropathy.
When used with an alpha blocker, take them at least four hours apart to avoid hypotension.
Chemical Synthesis
The preparation steps for synthesis of Viagra (sildenafil citrate) are as follows:
1. Methylation of 3-propylpyrazole-5-carboxylic acid ethyl ester with hot dimethyl sulfate.
2. Hydrolysis with aqueous NaOH to free acid.
3. Nitration with oleum/fuming nitric acid.
4. Carboxamide formation with refluxing thionyl chloride/NH4OH.
5. Reduction of nitro group to amino.
6. Acylation with 2-ethoxybenzoyl chloride.
7. Cyclization.
8. Sulfonation to the chlorosulfonyl derivative.
9. Condensation with 1-methylpiperazine.
Propoxyphene
Propoxyphene
Common brand names: Propoxyphene is a narcotic pain reliever found in Darvon, Darvocet N-100 and Darvon Compound-65.
Description: Propoxyphene is chemically unrelated to the codeine derivatives (codeine, hydrocodone or oxycodone). Propoxyphene is available as two preparations: propoxyphene hydrochloride (HCl) and propoxyphene napsylate. Approximately 65 milligrams of propoxyphene hydrochloride is equal to 100 milligrams of propoxyphene napsylate in terms of pain relief and side effects, with both preparations being equivalent to or slightly weaker than 60 milligrams of codeine.
When used alone at these dosages (as in Darvon), the analgesic effect is inferior to two aspirin or two Tylenol. Propoxyphene is most effective when it is combined with acetaminophen (as in Darvocet N-100) or aspirin (as in Darvon Compound-65).
Dental Uses: Propoxyphene is most commonly prescribed for relief of pain following dental surgery and for temporary relief of toothache.
Dosages for dental purposes: Generally effective prescriptions of propoxyphene include acetaminophen 650 milligrams plus propoxyphene napsylate 100 milligrams (Darvocet N-100), one tablet every four to six hours; or aspirin 389 milligrams, caffeine 32.4 milligrams and propoxyphene hydrochloride 65 milligrams (Darvon Compound-65), one tablet every four hours.
Concerns and possible side effects: Propoxyphene and other oral narcotics (codeine, hydrocodone and oxycodone) produce a relatively high incidence of dizziness, drowsiness, nausea, vomiting and constipation. Dental patients prescribed drugs containing oral narcotics should not operate dangerous machinery or drive automobiles. Alcohol consumption must be avoided while taking narcotics because the combination greatly increases the risk of drowsiness, impaired thinking and unconsciousness. Alcohol consumption also increases the risk for stomach bleeding and ulcers (from aspirin/propoxyphene combinations) and liver damage (from acetaminophen/propoxyphene combinations).
Short-term use of narcotic analgesics (a few days) for post-surgical dental pain does not lead to drug addiction. Concern among some health professionals about the ability of chronic narcotic therapy (of weeks or months duration) to lead to addiction in some patients is largely unfounded, but it is still the subject of debate.
Patients with allergies to acetaminophen should not consume Darvocet N-100, while those allergic to aspirin should avoid Darvon Compound-65. Allergic reactions can range from a mild rash to life-threatening closure of the airway and a fall in blood pressure.
Pilocarpine
Pilocarpine
Common brand name: Salagen
Dental uses: Pilocarpine is approved for the symptomatic relief of dry mouth (xerostomia) caused by radiation therapy for head and neck cancer; and for the symptomatic relief of dry mouth caused by Sjogren’s syndrome (an immune system disease).
Dosages for dental purposes: For dry mouth caused by radiation therapy, the recommended adult dose of pilocarpine is 5 milligrams to 10 milligrams three times per day. For dry mouth caused by Sjogren’s syndrome the recommended adult dose is 5 milligrams four times per day.
Concerns and possible side effects: Patients with a chronic dry mouth are at increased risk for dental decay and should see their dentist for treatment. The most common side effects from pilocarpine are sweating, runny nose, nausea, chills, dizziness, and increased urinary frequency. Patients with severe asthma should not take pilocarpine because pilocarpine may precipitate an asthmatic attack in these individuals. While pilocarpine is used in medicine to treat certain types of wide-angle glaucoma (increased eye pressure), it should not be taken by patients with narrow-angle glaucoma or acute iritis inflammation of the iris), because pilocarpine may precipitate a glaucoma attack in these individuals.
Penicillin VK
Penicillin VK
Common brand names: Pen-Vee K, V-Cillin K
Description: Penicillin VK is an antibiotic classified as a narrow-spectrum penicillin, meaning it kills a relatively small range of bacteria.
Dental Uses: For many dental infections, including dental abscesses, infections around wisdom teeth and infections after surgery, no other antibiotic works better, is safer and costs less than penicillin VK. Unlike its predecessor, penicillin G, penicillin VK can withstand stomach acid when swallowed.
Dosages for dental purposes: The typical adult dose is 250 milligrams to 500 milligrams every six hours for seven to 10 days. Dosages for children are based on body weight.
Concerns and possible side effects: Side effects occur occasionally and include nausea, vomiting and diarrhea. Occasionally, penicillin VK temporarily turns the tongue a black color, a condition called black hairy tongue. Penicillin VK and other penicillins should not be taken by people with documented allergies to these drugs. Allergic reactions can range from a mild rash to life-threatening closure of the airway and a fall in blood pressure.
Naproxen Sodium
Naproxen Sodium
Common brand names: Aleve, Anaprox.
Description: Naproxen sodium is a nonsteroidal anti-inflammatory drug (NSAID) that relieves pain, reduces fever and lessens swelling and other symptoms of arthritis.
Dental Uses: In dentistry, naproxen sodium is employed to treat pain from dental surgery, toothache, and the temporomandibular joint. A 220-milligram dose (that is, one Aleve) is roughly equal to the pain-relieving effects of the maximum prescribed doses of aspirin or acetaminophen (1,000 milligrams). For more severe dental pain, such as that following oral surgery, the analgesic effects of 440 to 550 milligrams of naproxen sodium (that is, two Aleve or one Anaprox) is superior to 1,000 milligrams of aspirin or acetaminophen and is at least equivalent to 600 milligrams of acetaminophen plus 60 milligrams of codeine (that is, two Tylenol #3s). Naproxen sodium is noted for its relatively long duration of action (eight to 12 hours).
Dosages for dental purposes: The generally effective prescription for naproxen sodium following dental surgery is 440 to 550 milligrams every eight to 12 hours as needed for pain. The maximum daily dose should not exceed 1,350 milligrams on the first day of therapy and 1,100 milligrams on subsequent days. The duration of therapy for post-surgical pain varies, but is usually less than five days. Naproxen sodium is not recommended for children under the age of 14.
Concerns and possible side effects: With short-term use (less than one week), common side effects include abdominal pain, nausea and increased bleeding time, with an incidence about equal to that of aspirin. Naproxen sodium also occasionally causes a dry mouth (xerostomia).
With chronic dosing (many weeks or months), as employed in the treatment of arthritis, more serious side effects can occur, often requiring hospitalization. These may include bleeding ulcers and perforations of the stomach and small intestines (occurring in 1 percent to 4 percent of patients) and impairment of kidney function. Still, under the typical dental usage scenario of a few days at most, naproxen sodium is generally a safe, well-tolerated and effective analgesic.
Patients allergic to aspirin or other NSAIDs (ibuprofen, diflunisal and many others) should avoid naproxen sodium. Allergic reactions can range from a mild rash to life-threatening closure of the airway and a fall in blood pressure. In addition, about 5 percent to 10 percent of patients with asthma — called aspirin- or NSAID-sensitive asthmatics — cannot tolerate aspirin, naproxen sodium, related NSAIDs, or COX-2 inhibitors because they will precipitate life-threatening asthmatic attacks.
Patients with ulcers of the stomach or the small intestine should avoid naproxen sodium. Patients should avoid alcohol consumption during naproxen sodium therapy for dental pain because alcohol increases the risk of stomach ulcers and bleeding.
Other drugs with which naproxen sodium may adversely interact include:
The manic-depression drug lithium (Eskalith), which when combined can lead to lithium toxicity
Warfarin (Coumadin) and other anticoagulants, which can lead to bleeding
Oral drugs for diabetes (ie, Diabinase and Orinase), which can lead to low blood sugar
Some high blood pressure medications, including beta blockers (propranolol, brand name Inderal), ACE inhibitors (enalapril, brand name Vasotec), and diuretics (hydrochlorothiazide, brand name Hydrodiuril). Combining any of these with naproxen may cause elevations in blood pressure.
These interactions can be serious, so it is imperative to inform your dentist of all medications you are taking.
Nystatin
Nystatin
Common brand names: Mycostatin, Nilstat.
Dental uses: Nystatin is an antifungal drug used to treat Candida albicans infections in the mouth, including moniliasis, thrush and denture stomatitis.
Dosages for dental purposes: Usual dose is 2 to 3 milliliters (½ teaspoon) of a suspension containing 100,000 units per milliliter of nystatin placed in each side of the mouth, swished, and held for at least five minutes before swallowing. This regimen is repeated every six hours for at least 10 days. Alternatively, one or two lozenges known as troches or pastilles containing 200,000 units of nystatin each may be allowed to slowly dissolve in the mouth four or five times per day for up to two weeks.
For fungal infections on the oral tissues under dentures, nystatin ointment (100,000 units per gram) can be applied to the tissue surface of the denture (and placed back in the mouth) every six hours for at least 10 days.
Concerns and possible side effects: The major patient complaint about nystatin is its bitter, foul taste. Occasionally nystatin produces nausea, vomiting and diarrhea.
Motrin
Ibuprofen
Common brand names: Advil, Nuprin, Motrin and many others.
Description: Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that relieves pain, reduces fever and lessens swelling and other symptoms of arthritis.
Dental Uses: In dentistry, ibuprofen is employed to treat pain from dental surgery, toothache, and the temporomandibular joint. A 200-milligram dose (that is, one Advil or one Nuprin) is roughly equal to the pain-relieving effects of the maximum prescribed doses of aspirin or acetaminophen (1,000 milligrams). For more severe dental pain, such as that following oral surgery, the analgesic effects of 400 milligrams of ibuprofen (that is, two Advil or two Nuprin) is superior to 1,000 milligrams of aspirin or acetaminophen and is at least equivalent to 600 milligrams of acetaminophen plus 60 milligrams of codeine (that is, two Tylenol #3s).
Dosages for dental purposes: The generally effective prescription for ibuprofen following dental surgery is 400 milligrams every four to six hours, as needed for pain. The maximum daily dose should not exceed 2,400 milligrams. The duration of therapy for post-surgical pain varies but is usually less than five days.
For more chronic pain of the temporomandibular joint, higher doses (600 to 800 milligrams every six to eight hours) may be needed, with a maximum daily dose of 3,200 milligrams. Daily dosing for children is based on age and body weight.
Concerns and possible side effects: With short-term use (less than one week), the most common side effects of ibuprofen include abdominal pain, nausea and increased bleeding time; incidences of these effects are lower, compared with aspirin. Ibuprofen also occasionally causes a dry mouth (xerostomia).
With chronic dosing (many weeks or months), as employed in the treatment of arthritis, more serious side effects can occur, often requiring hospitalization. These may include bleeding ulcers and perforations of the stomach and small intestines (occurring in 1 percent to 4 percent of patients) and impairment of kidney function. Still, under the typical dental usage scenario of a few days at most, ibuprofen is a very safe, well-tolerated and effective analgesic.
Patients allergic to aspirin or other NSAIDs (naproxen sodium, diflunisal and many others) should avoid ibuprofen. Allergic reactions can range from a mild rash to life-threatening closure of the airway and a fall in blood pressure. In addition, about 5 percent to 10 percent of patients with asthma cannot tolerate aspirin, ibuprofen, related NSAIDs, or COX-2 inhibitors, because they will precipitate life-threatening asthmatic attacks in these so-called aspirin or NSAID sensitive asthmatics, Patients with ulcers of the stomach or the small intestine should avoid ibuprofen.
Patients should avoid alcohol consumption during ibuprofen therapy because alcohol increases the risk of stomach ulcers and bleeding.
Other drugs with which ibuprofen may adversely interact include:
The manic-depression drug lithium (Eskalith), which when combined can lead to lithium toxicity
Warfarin (Coumadin) and other anticoagulants, which can lead to bleeding
Oral drugs for diabetes (Diabinase and Orinase), which can lead to low blood sugar
Some high blood pressure medications, including beta blockers (propranolol, brand name Inderal), ACE inhibitors (enalapril, brand name Vasotec), and diuretics (hydrochlorothiazide, brand name Hydrodiuril). Combining any of these with ibuprofen may cause elevations in blood pressure.
These interactions can be serious, so it is imperative to inform your dentist of all medications you are taking.
Moi-Stir
Saliva Substitutes
Common brand names: Moi-Stir, Mouth Kote, Optimoist, Saliva Substitute, Salivar, Salix, Xero-Lube.
Dental uses: Saliva substitutes are used for the symptomatic relief of dry mouth and dry throat in patients whose saliva levels are low or absent. These often are patients who received radiation therapy to the head and neck, or patients with Sjogren’s syndrome (an immune system disorder).
Dosage for dental purposes: Saliva substitutes are taken as often as needed, usually in the form of a spray. There are no specific dosage guidelines.
Concerns and possible side effects: Patients with a chronic dry mouth are at increased risk for dental decay and should see their dentist for treatment. Most saliva substitutes contain the sugar sorbitol, which can also increase the risk of dental decay. Topical fluoride treatments administered to protect the teeth in patients with a chronic dry mouth should also protect the teeth from any problem posed by sorbitol.
Minocin
Minocycline
Common brand names: Minocin, Dynacin.
Dental uses: Minocycline is a broad-spectrum, tetracycline-type antibiotic. It typically is prescribed for up to two weeks for different types of periodontal (gum) diseases, including periodontal disease in adolescents (juvenile periodontitis).
Dosages for dental purposes: The typical adult dose is 200 milligrams for the first dose followed by 100 milligrams every 12 hours for up to two weeks. Minocycline and all tetracyclines must not be ingested with dairy products (milk, yogurt), antacids (Tums, Rolaids, Maalox, Mylanta, Pepto-Bismol), or iron and zinc supplements because these products greatly inhibit the absorption of tetracyclines from the gastrointestinal tract into the bloodstream.
Concerns and possible side effects: Minocycline, like all tetracyclines, has a much higher incidence of side effects — such as nausea, vomiting, abdominal pain, diarrhea and yeast infections (in women) — than does penicillin VK. Occasionally, minocycline temporarily turns the tongue a black color, a condition known as black hairy tongue.
In addition, minocycline and all tetracyclines should not be prescribed to children under 8 years or to pregnant women, because they can permanently stain the teeth of the growing child or fetus.
Minocycline may produce a permanent grayish color on the gingiva (gums) and teeth in adults. Also, severe sunburn (photosensitivity) can occur in up to 10 percent of patients prescribed a tetracycline if adequate measures of sun protection (avoiding prolonged sun exposure and using sunscreens) are not undertaken.
