Midazolam
Midazolam
Common brand names: Versed Injection, Versed Syrup
Description: Midazolam is classified as an antianxiety, sedative and hypnotic drug; it relaxes the patient, makes him or her drowsy and induces sleep. It is closely related to diazepam (Valium).
Dental uses: Midazolam is used in dentistry as both an intravenous (given through a vein in the arm) sedative for anxious adult patients and as an oral sedative, given as a sweet-tasting syrup, to anxious and uncooperative pediatric patients. As an intravenous sedative, midazolam in now more widely used than diazepam because midazolam causes less burning sensations on injection and less venous irritation (pain).
Dosages for dental purposes: The dose of intravenous midazolam varies from patient to patient but is usually in the range of 1 milligram to 5 milligrams given immediately before the procedure. The dose of midazolam given to pediatric patients as an oral syrup is based on the child’s body weight and can range from 0.25 milligram to 1 milligrams per kilogram (2.2 pounds) with an absolute maximum dose of 20 milligrams.
Concerns and possible side effects: Intravenous midazolam should only be administered by practitioners with advanced training in anesthesiology (typically, oral surgeons and dental anesthesiologists). Patients must be properly monitored with a device known as a pulse oximeter, which measures heart rate and how well the patient is breathing. This is because occasionally, intravenous midazolam can impair breathing. Patients who are to undergo any form of intravenous sedation are encouraged to ask their doctors about their level of training and experience with these techniques.
Oral midazolam syrup also should be only administered by practitioners with advanced training in pediatric sedative techniques and anesthesiology (typically, pediatric dentists, dental anesthesiologists and oral surgeons). As with intravenous midazolam, pediatric patients receiving oral midazolam syrup must be properly monitored with a pulse oximeter, which measures heart rate and how well the patient is breathing. This is because occasionally, midazolam syrup can impair breathing.
Midazolam syrup causes nausea and/or vomiting in some patients. Sedation procedures with either oral or intravenous midazolam frequently cause drowsiness, forgetfulness, impaired thinking and lack of coordination. Therefore, adult patients should not operate machinery or drive automobiles, and pediatric patients must be well supervised by their parents and should refrain from outdoor activities for up to 24 hours.
Occasionally, midazolam may temporarily cause a dry mouth (xerostomia). Patients with narrow-angle glaucoma (increased pressure in the eye) should not take midazolam or related benzodiazepines (such as diazepam or triazolam) because these drugs can precipitate a glaucoma attack.
Pregnant women should not receive midazolam or related benzodiazepines because these drugs, especially when taken in the first trimester, increase the risk of birth defects.
Certain other drugs may cause midazolam to accumulate in the body and increase the risks of side effects. These include:
The antibiotics erythromycin (Eryc) and clarithromycin (Biaxin)
Azole antifungal drugs such as ketoconazole (Nizoral) and fluconazole (Diflucan)
The ulcer medications cimetidine (Tagamet) and omeprazole (Prilosec)
This list is not complete and it continues to grow. These interactions can be serious, so it is imperative to inform your dentist of all medications you are taking.
Metryl
Metronidazole
Common brand names: Flagyl, Metryl
Dental uses: Metronidazole is a synthetic antimicrobial agent originally introduced in the 1960s for the treatment of vaginitis. Its primary use in dentistry is in the treatment of infections caused by anaerobic bacteria (bacteria that do not require oxygen to survive). It is used alone in the treatment of a periodontal infection known as acute necrotizing ulcerative gingivitis (ANUG). It is combined with penicillin VK, amoxicillin or other antibiotics for the treatment of infected jaw fractures, various periodontal infections and endodontic infections.
Dosages for dental purposes: The typical adult dose of metronidazole is 250 milligrams to 750 milligrams every eight hours for seven to 10 days.
Concerns and possible side effects: Metronidazole produces a higher incidence of nausea, possibly accompanied by diarrhea, vomiting, and abdominal pain than does penicillin VK. It also produces a sharp, unpleasant metallic taste in some patients. Irritation and ulcers of the tongue, gingiva and other oral soft tissues occasionally occur in patients taking metronidazole.
Metronidazole should not be taken with alcohol or within three days of alcohol ingestion because the combination can produce headaches, facial flushing, heart palpitations, nausea and vomiting.
Metronidazole can increase the toxicity of certain drugs, including the manic-depressive medication lithium (Eskalith) and the blood-thinning agent warfarin (Coumadin). These interactions can be serious, so it is imperative to inform your dentist of all medications you are taking.
Metronidazole
Metronidazole
Common brand names: Flagyl, Metryl
Dental uses: Metronidazole is a synthetic antimicrobial agent originally introduced in the 1960s for the treatment of vaginitis. Its primary use in dentistry is in the treatment of infections caused by anaerobic bacteria (bacteria that do not require oxygen to survive). It is used alone in the treatment of a periodontal infection known as acute necrotizing ulcerative gingivitis (ANUG). It is combined with penicillin VK, amoxicillin or other antibiotics for the treatment of infected jaw fractures, various periodontal infections and endodontic infections.
Dosages for dental purposes: The typical adult dose of metronidazole is 250 milligrams to 750 milligrams every eight hours for seven to 10 days.
Concerns and possible side effects: Metronidazole produces a higher incidence of nausea, possibly accompanied by diarrhea, vomiting, and abdominal pain than does penicillin VK. It also produces a sharp, unpleasant metallic taste in some patients. Irritation and ulcers of the tongue, gingiva and other oral soft tissues occasionally occur in patients taking metronidazole.
Metronidazole should not be taken with alcohol or within three days of alcohol ingestion because the combination can produce headaches, facial flushing, heart palpitations, nausea and vomiting.
Metronidazole can increase the toxicity of certain drugs, including the manic-depressive medication lithium (Eskalith) and the blood-thinning agent warfarin (Coumadin). These interactions can be serious, so it is imperative to inform your dentist of all medications you are taking.
Lotrimin
Clotrimazole
Common brand names: Mycelex, Lotrimin
Description: Clotrimazole is an antifungal drug best known for treating vaginal yeast infections in women.
Dental uses: Clotrimazole is available as a troche (lozenge) for treating fungal infections in the mouth. It is considered by some to be the drug of choice for the treatment of candidal fungal infections (thrush) in the mouths of some patients with AIDS. It is pleasant tasting and far more palatable than nystatin.
Dosages for dental purposes: The typical dose is to dissolve one 10-milligram clotrimazole troche in the mouth five times per day for 14 days. A 1-percent clotrimazole ointment can be applied directly to the involved oral tissues four times per day for denture stomatitis.
Concerns and possible side effects: Clotrimazole can cause occasional burning and irritation on application, and occasional nausea.
Keflex
Cephalexin
Common brand names: Keflex, Biocef
Description: Cephalexin is a cephalosporin-type antibiotic closely related to penicillins.
Dental Uses: It is occasionally used to treat dental infections that are resistant to penicillin VK. However it must be stressed that most dental infections can be better and less expensively treated with penicillin VK.
The other use of cephalexin in dentistry is to prevent joint infections in certain patients with prosthetic joints of the hip, knee or elbow who are scheduled to undergo dental procedures likely to induce mucosal or gingival bleeding. Such procedures include dental extractions, periodontal surgery, professional cleanings, orthodontic band (not bracket) placement and some other procedures.
Dosages for dental purposes: The typical adult dose of cephalexin for dental infections is 250 milligrams to 500 milligrams every six hours for seven to 10 days.
The recommended dose of cephalexin for patients at risk of joint infections is 2 grams (four 500-milligram capsules) an hour before the dental procedure. This single-dose regimen is generally well tolerated.
Concerns and possible side effects: Cephalexin produces a higher incidence of abdominal pain, diarrhea, nausea and vomiting than penicillin VK.
Approximately 10 percent of patients allergic to penicillins also are allergic to cephalosporins. Allergic reactions can range from a mild rash to life-threatening closure of the airway and a fall in blood pressure. Cephalosporins must be avoided or used with extreme caution in patients with documented penicillin allergies.
Ibuprofen
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.
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.
Hydrocodone
Hydrocodone
Description: Hydrocodone is a narcotic analgesic (pain reliever) closely related to codeine that is most effective for dental pain when given in combination with acetaminophen (as in Vicodin and Lortab preparations) or ibuprofen (as in Vicoprofen).
Dental Uses: Hydrocodone is most commonly prescribed for relief of pain following dental surgery and for temporary relief of toothache. It occasionally is prescribed for chronic pain of the jaw (temporomandibular joint pain) or face. Hydrocodone is approximately six times more powerful than codeine, so that 10 milligrams of hydrocodone produces the same pain relief and side effects as 60 milligrams of codeine. This does not mean that hydrocodone is a better drug than codeine. It is simply “stronger,” so your dentist has to prescribe less of it.
Dosages for dental purposes: Generally effective hydrocodone prescriptions include:
Acetaminophen 500 milligrams plus hydrocodone 5 milligrams (Vicodin or Lortab 5/500), one or two tablets every four to six hours
Acetaminophen 750 milligrams plus hydrocodone 7.5 milligrams (Vicodin ES), one tablet every six hours
Ibuprofen 200 milligrams plus hydrocodone 7.5 milligrams (Vicoprofen), one tablet every four to six hours.
The duration of therapy for post-surgical pain varies but is usually less than five days.
Concerns and possible side effects: Hydrocodone and other oral narcotics (codeine, oxycodone and propoxyphene) produce relatively high incidences of dizziness, drowsiness, nausea, vomiting and constipation in dental-surgery patients. 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 of stomach bleeding and ulcers from ibuprofen/hydrocodone combinations and liver damage from acetaminophen/hydrocodone 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 cause addiction in some patients is largely unfounded, but it is still the subject of debate.
Patients with allergies to codeine should avoid hydrocodone. Patients with allergies to acetaminophen should not consume the Vicodin or Lortab preparations.
Patients with allergies to aspirin, ibuprofen or other nonsteroidal anti-inflammatory drugs should avoid Vicoprofen. Allergic reactions can range from a mild rash to life-threatening closure of the airway and a fall in blood pressure.
Halcion
Triazolam
Common brand name: Halcion
Description: Triazolam is classified as an antianxiety, sedative and hypnotic drug; it relaxes the patient, makes him or her drowsy and induces sleep. It is closely related to diazepam (Valium) but is shorter-acting.
Dental uses: The main use of triazolam in dentistry is to relax and sedate patients prior to dental procedures and to improve sleep the night before a dental procedure in anxious patients.
Dosages for dental purposes: The typical adult dose is 0.25 milligram right before bedtime the night before the dental procedure to improve sleep, and then 0.25 milligram to 0.50 milligram one hour prior to the dental procedure to relax and sedate the patient.
Concerns and possible side effects: When given by mouth (orally), triazolam and related benzodiazepines (for example, diazepam) are considered a very safe group of antianxiety-sedative-hypnotic drugs. However drowsiness, forgetfulness, impaired thinking and lack of coordination frequently occur. Therefore patients should not operate machinery or drive automobiles for up to 24 hours after taking triazolam.
Occasionally, triazolam may temporarily cause a dry mouth (xerostomia). Patients with narrow-angle glaucoma (increased pressure in the eye) should not take triazolam or related benzodiazepines (ie, diazepam or midazolam) because these drugs can precipitate a glaucoma attack.
Pregnant women should not receive triazolam or related benzodiazepines because these drugs, especially when taken in the first trimester, increase the risk of birth defects.
Patients should not drink alcohol during triazolam therapy. The combination can increase the severity of drowsiness, forgetfulness, impaired thinking and lack of coordination, and possibly lead to unconsciousness.
Certain other drugs may cause triazolam to accumulate in the body and increase the risks of side effects. These include:
The antibiotics erythromycin (Eryc) and clarithromycin (Biaxin)
Azole antifungal drugs such as ketoconazole (Nizoral) and fluconazole (Diflucan)
The ulcer medications cimetidine (Tagamet) and omeprazole (Prilosec)
This list is not complete and it continues to grow. These interactions can be serious, so it is imperative to inform your dentist of all medications you are taking.
Glycopyrollate
Common brand names: Robinul, Robinul-Forte
Dental uses: Glycopyrollate is used to reduce salivation (to dry the mouth) before certain dental procedures, such as impressions for extensive crown and bridge work.
Dosages for dental purposes: The typical adult dosage is 1 milligram to 2 milligrams one hour before the dental procedure.
Concerns and possible side effects: The most common side effects of glycopyrollate are dry mouth, decreased sweating, increased heart rate and blurred vision. Glycopyrollate should be used cautiously in patients with heart disease. Patients with narrow-angle glaucoma (increased pressure in the eye) should not take glycopyrollate, because glycopyrollate may precipitate a glaucoma attack.