Prescriptions in Oral medicine DEPARTMENT OF ORAL MEDICINE

Prescriptions in Oral medicine DEPARTMENT OF ORAL MEDICINE & RADIOLOGY Dentistry Explorer

What is prescription ? An official piece of paper on which a doctor writes the type of medication you should have. Oxford Advanced Learner’s Dictionary 6 th edition Dentistry Explorer

What is drug ? Drug is a substance or product that is used or is intended to be used to modify or explore physiological systems or pathological states for the benefit of the recipient. WHO (1966) Dentistry Explorer

Drug nomenclature A drug generally has three categories of names : 1. Chemical name : It describes the substance chemically. e. g. 2 -Diethylamino 2, 6 -acetoxylidide hydrochloride for Lidocaine (Lignocaine) 2. Non-proprietary name : It is the name accepted by competent scientific body such as United States Adopted Name (USAN). e. g. Lidocaine 3. Proprietary (Brand) name : It is the name assigned by the manufacturers. e. g. Xylocaine, Gesicain, Lignospan Dentistry Explorer

Routes of drug administration : Most drugs can be administered by a variety of routes. The choice of appropriate route in a given situation depends both on drug as well as patient related factors. Factors governing the choice of route : 1. Physical and chemical properties of the drug ( solid / liquid / gas ; solubility , stability , p. H , irritancy ) 2. Site of desired action : Localized and approachable or generalized and not approachable. Dentistry Explorer

Routes of drug administration contd… 3. Rate and extent of absorption of the drug from different routes. 4. Effect of digestive juices and first pass metabolism on the drug. 5. Rapidity with which the response is desired ( routine treatment or emergency ). 6. Accuracy of dosage required ( i. v. and inhalation can provide fine tuning ). 7. Condition of the patient ( unconscious , vomiting ). Dentistry Explorer

Routes of drug administration contd… 1. Local routes : These routes can only be used for localized lesions at accessible sites. a. Topical : This refers to external application of the drug to the surface for localized action. It is often more convenient as well as encouraging to the patient. e. g. Skin – as ointment, cream , powder, spray , etc. Mucous membrane - as paints, lozenges, mouth washes, gargles, etc. b. Deeper tissues : Certain deep areas can be approached by using a syringe and needle, but the drug should be such that systemic absorption is slow. e. g. Intra – articular injection ( hydrocortisone acetate ) Intrathecal injection ( lidocaine, amphoterecin B ) Retrobulbar injection ( hydrocortisone acetate ). c. Arterial supply : Close intra-arterial injection is used for contrast media in angiography. Dentistry Explorer

Routes of drug administration contd… 2. Systemic routes : The drug administered through systemic routes is intended to be absorbed into blood and disributed all over, including the site of action, through circulation. a. Oral : e. g. Solid dosage forms – tablets, capsules Liquid dosage forms – syrups, emulsions. b. Sublingual or Buccal : e. g. Nitroglycerine, Clonidine. c. Rectal : e. g. Diazepam, Indomethacin. d. Cutaneous : Highly lipid soluble drugs as ointments. e. g. Transdermal therapeutic systems – Nitroglycerine, insulin. e. f. Inhalation : e. g. General Anaesthetics. Nasal : e. g. Desmopressin. Dentistry Explorer

Routes of drugs administration contd… g. Parenteral : This refers to the administration by injection which takes the drug directly into the tissue fluid or blood without having to cross the intestinal mucosa. i. Subcutaneous ( s. c. ) : The drug is deposited in the loose subcutaneous tissue which is richly supplied by nerves ( irritant drugs can be injected ) but less vascular ( absorption is slower ) e. g. Japanese Encephalitis, Rabies vaccine. ii. Intramuscular ( i. m. ) : The drug is injected in one of the large skeletal muscles like Deltoid, Triceps. e. g. Measles vaccine, Tetanus Toxoid vaccine. iii. Intravenous ( i. v. ) : The drug is injected as a bolus or infused slowly over hours in one of the superficial veins. e. g. 0. 9 % normal saline, 5 % dextrose. iv. Intradermal ( i. d ) : The drug is injected into the skin raising a bleb. e. g. BCG vaccine. Dentistry Explorer

Oral medicine is a specialty within dentistry that focus on the diagnosis and management of complex diagnostic and medical disorders affecting the mouth and jaws. Burket’s Oral medicine -11 th Edition Clinicians with advanced training in this discipline manage oral mucosal disease, salivary gland disorders, facial pain syndromes and also provide dental care for patients with complicating medical disease. Dentistry Explorer

Oral mucosal diseases 1. a. • • Ulcerative, Vesicular, and Bullous Lesions : Acute multiple lesions : Herpes Simplex Virus Infection Varicella-Zoster Virus Infection Cytomegalovirus Infection Coxackievirus Infection Necrotizing Ulcerative gingivitis and Periodontitis Erythema Multiforme Stevens Johnson Syndrome and Toxic Epidermal Necrolysis ( Lyell disease ) Dentistry Explorer Oral Hypersensitivity Reactions

Oral mucosal diseases b. Recurring Oral Ulcers : • Recurrent Aphthous Stomatitis • Behcet Disease ( Behcet Syndrome ) Dentistry Explorer

c. • • • Oral mucosal diseases Chronic Multiple Lesions : Pemphigus Vulgaris Paraneoplastic Pemphigus Vegetans Subepithelial Bullous Dermatitis Bullous Pemphigoid Mucous Membrane Pemphigoid ( Cisatrical Pemphigoid ) Linear Ig. A Disease Epidermolysis Bullosa Aquisita Chronic Bullous Disease of Childhood Dentistry Explorer

Oral mucosal diseases d. Single Ulcers : • Traumatic Injuries Causing Solitary Ulcerations • Traumatic Ulcerative Granuloma ( Eosinophilic Ulcer of Tongue ) • Histoplasmosis • Blastomycosis • Mucormycosis ( Phycomycosis ) Dentistry Explorer

Oral mucosal diseases 2. Red and White Lesions of the Oral Mucosa : a. b. • • c. • • Red and White Tissue Reactions : Infectious Diseases : Oral Candidiasis Hairy Leukoplakia Premalignant Lesions : Oral Leukoplakia and Erythroplakia Oral Submucous Fibrosis Dentistry Explorer

Oral mucosal diseases d. • • e. • • Immunopathologic Diseases : Oral Lichen Planus Drug-Induced Lichenoid Reactions of Graft-Versus-Host Disease Lupus Erythematosus Allergic Reactions : Lichenoid Contact Reactions To Dentifrice and Chlorhexidine Dentistry Explorer

Oral mucosal diseases f. • • g. • h. • • Toxic Reactions : Reactions to Smokeless Tobacco Smoker’s Palate Reactions to Mechanical Trauma : Morsicatio Other Red and white Lesions : Benign Migratory Glossitis ( Geographic Tongue ) Leukoedema White Sponge Nevus Hairy Tongue Dentistry Explorer

Oral mucosal diseases 3. a. b. • • • Pigmented Lesions of the Oral Mucosa : Endogenous Pigmentation : Focal Melanotic Pigmentation : Freckle / Ephelis Oral / Labial Melanotic Macule Oral Melanoacanthoma Melanocytic Nevus Malignant Melanoma Dentistry Explorer

Oral mucosal diseases c. Multifocal / Diffuse Pigmentation : • • • Physiologic Pigmentation Drug-Induced Melanosis Smoker’s Melanosis Postinflammatory ( inflamatory ) Hyperpigmentation Melasma (Chloasma ) Dentistry Explorer

Oral mucosal diseases d. Melanosis Associated with Systemic or Genetic Disease : • Hypoadrenocorticism ( Adrenal Insuffiency, Addison’s Disease ) • Cushing’s Syndrome / Cushing’s Disease • Hyperthyroidism ( Grave’s Disease ) • Primary Biliary Cirrhosis • Vitamin B 12 ( Cobalamin ) Deficiency • Peutz-Jeghers Syndrome • Café au Lait Pigmentation • HIV/ AIDS- Associated. Dentistry Melanosis Explorer

Oral mucosal diseases e. • f. g. • h. • • • Idiopathic Pigmentation : Laugier-Hunziker Pigmentation Treatment of Mucocutaneous Melanosis : Depigmentation Vitiligo Hemoglobin and Iron-Associated Pigmentation : Ecchymosis Purpura / Petechiae Hemochromatosis Dentistry Explorer

Benign lesions of oral cavity 1. 2. • • Variants of normal : Benign Soft Tissue Lesions : Inflammatory / Reactive Hyperplasia of Soft Tissue Benign Soft Tissue Tumors Dentistry Explorer

Benign lesions of oral cavity 3. • • Benign Lesions of Bone : Benign Fibro-osseous Lesions Fibrous Dysplasia Langerhans’ Cell Histiocytosis Giant Cell Lesions of Bone Paget’s Disease of Bone Cysts of Jaws and Adjacent Soft Tissues Odontogenic Tumors Benign Non-odontogenic Tumors of the Jaw Dentistry Explorer

Oral cancers 1. 2. • • • 3. 4. • • 5. Squamous Cell Carcinoma : Other Head and Neck Cancers : Malignant Tumors of Salivary Glands Basal Cell Carcinoma Malignant Melanoma Pretreatment Oral and Dental Assessment Complications of Cancer Treatment : Mucositis Hyposalivation Management of Pain Dentistry in Orofacial Cancer Explorer

Salivary Gland Diseases 1. 2. 3. 4. Salivary gland infections Salivary gland hypofunction (xerostomia) Salivary gland hyperfunction (Sialorrhea) Salivary Gland Tumors Dentistry Explorer

Temporomandibular Disorders Dentistry Explorer

Orofacial pain 1. Facial Neuralgias 2. Complex Regional Pain Syndrome ( Reflex Sympathetic Dystrophy ) 3. Atypical Odontalgia (Atypical Facial Pain ) 4. Burning Mouth Syndrome ( Glossodynia ) 5. Vascular pain Dentistry Explorer

Headache 1. 2. 3. 4. 5. Migrane Tension-type Headache Cluster Headache Temporal Arteritis Chronic Paroxysmal Hemicrania Dentistry Explorer

Abbreviations Once daily Twice daily Three times daily Four times daily At bed time o. d. omni die b. d. /b. i. d. bis in die t. d. s. /t. i. d. ter in die q. i. d. /q. d. s. quater die sumendus h. s. hora somni Dentistry Explorer

Abbreviations contd. . . Orally Intramuscular Intravenous Subcutaneous Rectally As required p. o. per os i. m. i. v. s. c. p. r. per rectus s. o. s. si opus sit Dentistry Explorer

Highlights : Drugs : 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. Mechanism of action Generic name Brand name Indication Administration Prescription / OTC Dosage Duration Contraindication Common side effects Unusual but important side effects Drug interactions Monitoring Dentistry Explorer

Topical Analgesic Medications • • • Lidocaine Diphenhydramine Benzocaine Capsaicin Doxepin Dentistry Explorer

Lidocaine Mechanism of action : • Blocks nerve conduction by decreasing the entry of Sodium ions during upstroke of action potential. Dentistry Explorer

Topical Analgesic Medications Generic name-Lidocaine Brand name- XYLOCAINE, GESICAIN Indications- Mucosal pain Superficial facial pain Administration-Topical patch Topical gel Solution Prescription/OTC-Prescription Dosage- Patch : apply up to 12 h/d Gel 2. 5% : apply 6 -8 times/d Solution : 2% (20 mg/ml) : rinse and expectorate 10 cc q. i. d. s. o. s. Contraindications-Allergy Common side effects-Local erythema , edema, burning Unusual but important side effects- Anaphylaxis Drug interactions- Acetaminophen Monitoring-None Dentistry Explorer

Capsaicin Mechanism of action : Blocks C-fiber conduction, inactivates the release of neuropeptides from peripheral nerve endings and subsequently depletes the stores of substance P from sensory neurons. Dentistry Explorer

Topical Analgesic Medications Generic name-Capsaicin Brand name- ALGIPAN Indications- Stomatodynia Superficial neuropathic facial pain Administration-Topical cream Prescription/OTC-OTC/ Prescription Dosage- 0. 025%, 0. 075% cream : apply t. i. d. / q. i. d. for at least 2 weeks Contraindications-Allergy Common side effects. Unusual but important side effects- Neurotoxicity Drug interactions- None Monitoring-None Dentistry Explorer

Systemic Non steroidal Antiinflammatory Drugs • • • Ibuprofen Naproxen Flurbiprofen Ketoprofen Celecoxib Diflunisal Ketorolac Meloxicam Nabumetone Dentistry Explorer

Systemic Non steroidal Antiinflammatory Drugs Mechanism of action : • Block cycloxygenase and prostaglandin synthesis , thereby reducing inflammation and pain due to nociceptor sensitization. Dentistry Explorer

Systemic Non steroidal Antiinflammatory Drugs Generic name- Ibuprofen Brand name- BRUFEN, EMFLAM Indication- Mild to moderate nociceptive pain Administration- Tablets, liquid Prescription / OTC- Prescription and OTC Dosage – Tablets: 200 -400 mg t. d. s. for 5 -7 d Liquid: 20 -40 mg/cc solution t. d. s. for 5 -7 d Dentistry Explorer

Systemic Non steroidal Antiinflammatory Drugs Generic name-Naproxen Brand name- NAPROXYN, NAXID Indication – Mild to moderate nociceptive pain Administration- Tablets, liquid Prescription / OTC- Prescription and OTC Dosage – Tablets: 250 -500 mg t. d. s. Liquid: 125 mg/5 ml solution t. d. s. Dentistry Explorer

Systemic Non steroidal Antiinflammatory Drugs Generic name- Flurbiprofen Brand name- ARFLUR, FLUROFEN Indication – Mild to moderate nociceptive pain Administration- Tablets Prescription / OTC- Prescription Dosage – 50 -100 mg t. d. s. Dentistry Explorer

Systemic Non steroidal Antiinflammatory Drugs Generic name-Ketoprofen Brand name-KETOFEN, OSTOFEN Indication- Mild to moderate nociceptive pain Administration- Tablets Prescription / OTC- Prescription Dosage – 25 -50 mg t. d. s. / q. i. d. Dentistry Explorer

Systemic Non steroidal Antiinflammatory Drugs Generic name- Celecoxib Brand name-CELACT, REVIBRA Indication- Mild to moderate nociceptive pain Administration- Tablets Prescription / OTC- Prescription Dosage – 100 -200 mg b. d. Dentistry Explorer

Systemic Non steroidal Antiinflammatory Drugs Generic name-Ketorolac Brand name- KETOROL, ZOROVON Indication – Moderate to severe pain Administration- Tablets, IM injections Prescription / OTC- Prescription Dosage – tablets: 10 mg q. i. d. IM: 30 mg q. i. d. Dentistry Explorer

Systemic Non steroidal Antiinflammatory Drugs Generic name- Meloxicam Brand name-MELFLAM, MEL-OD Indication- Arthritis (TMD) Administration- Tablets Prescription / OTC- Prescription Dosage – 7. 5 -15 mg o. d. Dentistry Explorer

Systemic Non steroidal Antiinflammatory Drugs Generic name-Nabumetone Brand name- NABUFLAM Indication - Arthritis Administration- Tablets Prescription / OTC- Prescription Dosage – 1000 -2000 mg o. d. /b. d. Dentistry Explorer

Contraindication – Allergy, renal or liver impairment, combination with anticoagulant or antiplatelet medications Common side effects-Dyspepsia, nausea, abdominal pain, headache, dizziness, Somnolence, rash, elevated liver enzymes, constipation, fluid retention, peripheral edema, tinnitus, ecchymosis Unusual but important side effects- GI bleeds and ulcers, myocardial infarction, dermatitis, stroke, thromboembolism, hypertension, congestive heart failure, nephrotoxicity, hepatotoxicity, bronchospasm, anaemia, blood dyscrasias, Steven Johnson syndrome, toxic epidermal necrolysis Interactions- Aspirin: increases risk of bleeding, reduces cardioprotective effects Mycophenolate mofetil: increases risk of bleeding and nephrotoxicity Gabapentin: somnolence SSRIs: increases risk of bleeding Tacrolimus: increases risk of nephrotoxicity Monitoring-With chronic use: Complete Blood Count Dentistry Explorer

Opiate analgesics • • Codeine sulphate Hydromorphone Meperidine Tramadol Oxycodone Morphine sulfate ER Oxycodone ER Fentanyl Dentistry Explorer

Opiate Mechanism of action : • Acts by interaction with specific receptors present on neurones in the Central Nervous System and peripheral tissues and mimicking the effect of the endogenous pain-relieving chemicals dynorphin, enkephalin and β-enborphin. • Receptors - µ, ĸ, δ Dentistry Explorer

Opiate analgesics Generic name-Codeine sulphate Brand name- Generic Indication - Moderate to severe nociceptive pain Administration- Tablets Prescription / OTC- Prescription Dosage – Tablets : 15 -60 mg q. i. d. s. o. s. Dentistry Explorer

Opiate analgesics Generic name- Meperidine/Pethidine Brand name- PETHIDINE HCL Indication : Moderate to severe nociceptive pain Administration- Tablets, IM, SC Prescription / OTC- Prescription Dosage – Tablets, IM, SC: 50 -150 mg 6 -8 times/d Dentistry Explorer

Opiate analgesics Generic name-Tramadol Brand name- CONTRAMAL, DOMADOL Indication : moderate to severe nociceptive pain Administration- CAPSULE Prescription / OTC- Prescription Dosage – Tablets: 50 -100 mg q. i. d. s. o. s. Dentistry Explorer

Opiate analgesics Generic name-Morphine sulfate ER Brand name- MORPHINE SULFATE, MORCONTIN Indication –Continuous/chronic moderate to severe pain; extended release form Administration- Tablets Prescription / OTC- Prescription Dosage – Tablets 15 -30 mg t. d. s. / b. d. Dentistry Explorer

Contraindication – Allergy; watch combination with other opiates and sedatives; impaired renal or liver function; history of seizure disorder Common side effects- Hypotension, sedation and mental clouding, dizzy, constipatiuon, nausea, urinary retention, itching, asthma, respiratory depression, palpitations, xerostomia; dependency with prolonged use, abuse potential Unusual but important side effects- Respiratory or CNS depression, shock, cardiac arrest, paralytic ileus, bradycardia. Drug Interactions- Alcohol: increases sedation Anticholinergics: increase constipation CNS depressants: increase sedation Monitoring- Therapeutic drug levels in chronic use, addiction Dentistry Explorer behaviour, functional and cognitive assessment

Combination NSAID-Opiate Analgesics Generic name- Acetaminophen Brand name- Tylenol #3 + codeine Indication - Moderate to severe nociceptive pain Administration- Tablets and liquid Prescription / OTC- Prescription Dosage – Acetaminophen: 300 mg Codeine: 30 mg 2 tablets q. i. d. p. o. s. Dentistry Explorer

Combination NSAID-Opiate Analgesics Generic name- Hydrocodone + Acetaminophen Brand name-Vicodin Lorcet Lortab Norco Indication- Moderate to severe nociceptive pain Administration- Tablets Prescription / OTC- Prescription Dosage – Acetaminophen: 500 mg Hydrocodone: 5 mg 2 tablets q. i. d. p. o. s. Dentistry Explorer

Combination NSAID-Opiate Analgesics Generic name- Hydrocodone Brand name- Vicoprofen + Ibuprofen Indication – Moderate to severe nociceptive pain Administration- Tablets Prescription / OTC- Prescription Dosage – Ibuprofen: 200 mg Hydrocodone: 7. 5 mg 1 tablet q. i. d. p. o. s. Dentistry Explorer

Combination NSAID-Opiate Analgesics Generic name- Oxycodone + Acetaminophen Brand name-Percocet Roxicet Endocet Tylox Indication - Moderate to severe nociceptive pain Administration- Tablets, liquids Prescription / OTC- Prescription Dosage – Acetaminophen: 325 -500 mg Oxycodone: 2. 5 -7. 5 mg; 2 tablets q. i. d. p. o. s Dentistry Explorer

Combination NSAID-Opiate Analgesics Generic name-Aspirin Brand name-Empirin #3 + Codeine Indication - Moderate to severe nociceptive pain Administration- Tablets Prescription / OTC- Prescription Dosage – Aspirin: 325 mg Codeine: 30 mg 1 -2 tablets q. i. d. p. o. s. Dentistry Explorer

Combination NSAID-Opiate Analgesics Generic name-Acetaminophen + Propoxyphene napsylate Brand name- Darvocet Indication – Moderate to severe nociceptive pain Administration- Tablets Prescription / OTC- Prescription Dosage – Acetaminophen: 500 mg Propoxyphene: 100 mg 1 tablet q. i. d. p. o. s. Dentistry Explorer

Combination NSAID-Opiate Analgesics Generic name-Ibuprofen Brand name- Combunox + Oxycodone Indication – Moderate to severe nociceptive pain Administration- Tablets Prescription / OTC- Prescription Dosage – Ibuprofen: 400 mg Oxycodone: 5 mg 1 tablet q. i. d. p. o. s. Dentistry Explorer

Chlorhexidine Mouthwash Bactericidal and Bacteriostatic Mechanism of action : • Chlorhexidine is a chemical antiseptic. It is bacteriostatic at low concentration and bactericidal at high concentration also useful against fungi. Dentistry Explorer

Chlorhexidine for Treatment of Gingivitis Generic name-Chlorhexidine 0. 2 % rinse Brand name-CHX, CHLORHEXIDINE Indications-Gingivitis Administration-Rinse Prescription/OTC-Prescription Dosage-10 ml (1: 1)rinse and expectorate bid for 10 days Contraindications-Allergy Common side effects-Dental staining, calculus build-up, taste changes Drug interactions- none Monitoring-Clinical efficacy Dentistry Explorer

Antibiotics • • • Penicillin VK Amoxicillin Clavulanate Potassium Cephalosporins Clindamycin Tetracycline Azithromycin Vancomycin HCL Imipenem/Cilastatin Dentistry Explorer

Oral Antibiotics B-lactam antibiotics Mechanism of action : • Acts by inhibiting the synthesis of bacterial cell walls. • It inhibits cross-linkage between the linear peptidoglycan polymer chains that make up a major component of the cell walls of both Gram-positive and Gram-negative bacteria. Dentistry Explorer

Oral Antibiotics Generic name- Penicillin VK Brand name- CRYSTAPEN-V, KAYPEN Indications- Bacterial infection Administration- Tablets Prescription/OTC- prescription Dosage- 500 mg t. d. s. x 7 -10 d Contraindications- Documented hypersensitivity Common side effects-Rash, nausea, abdominal pain, diarrhoea Unusual but important side effects-Acute allergic reaction and anaphylaxis Drug interactions-Chloroquine phosphate, methotrexate Monitoring- Clinical efficacy Dentistry Explorer

Oral Antibiotics Generic name- Amoxicillin Brand name- AMOXYLIN, NOVAMOX Indications- Bacterial infection Administration-Capsule Prescription/OTC-Prescription Dosage- 250 -500 mg t. d. s. x 7 d Contraindications- Documented hypersensitivity Common side effects-Rash, nausea, abdominal pain, diarrhoea Unusual but important side effects-Acute allergic reaction and anaphylaxis Drug interactions- Probenacid, chloramphenicol, macrolides, sulfonamides, tetracyclines Monitoring- Clinical efficacy Dentistry Explorer

Oral Antibiotics Clindamycin Mechanism of action : • Clindamycin has a bacteriostatic effect. It is a bacterial protein synthesis inhibitor by inhibiting ribosomal translocation. • It does so by binding to the 50 S r. RNA of the large bacterial ribosome subunit. Dentistry Explorer

Oral Antibiotics Generic name- Clindamycin Brand name- DALCAP, CLINCIN Indications- Bacterial infection Administration-Capsule Prescription/OTC-Prescription Dosage- 300 mg q. i. d. x 7 d Contraindications- Documented hypersensitivity Common side effects-Rash, nausea, abdominal pain, diarrhoea Unusual but important side effects-Acute allergic reaction and anaphylaxis Drug interactions- Exenatide, contraceptives, mycophenolate, neuromuscular blockers Monitoring- Clinical efficacy Dentistry Explorer

Oral Antibiotics Tetracycline Mechanism of action : • Tetracycline antibiotics are protein synthesis inhibitors, inhibiting the binding of aminoacyl-t. RNA to the m. RNA-ribosome complex. They do so mainly by binding to the 30 S ribosomal subunit in the m. RNA translation complex. Dentistry Explorer

Oral Antibiotics Generic name-Tetracycline Brand name- ACHROMYCIN, HOSTACYCLINE Indications- Bacterial infection, Pemphigoid Administration-Capsule Prescription/OTC-Prescription Dosage- 250 -500 mg q. i. d. x 7 d Contraindications- Documented hypersensitivity Common side effects-Rash, nausea, abdominal pain, diarrhoea Unusual but important side effects-Acute allergic reaction and anaphylaxis Drug interactions- Acitretin, retinoids, aminolevulinic acid, hydroquinone, methoxsalen Monitoring- Clinical efficacy Dentistry Explorer

Oral Antibiotics Azithromycin Mechanism of action : • Azithromycin prevents bacteria from growing by interfering with their protein synthesis. Azithromycin binds to the 50 S subunit of the bacterial ribosome, and thus inhibits translation of m. RNA. Nucleic acid synthesis is not affected. Dentistry Explorer

Oral Antibiotics Generic name- Azithromycin Brand name- AZITHRAL, AZIWOK Indications- Bacterial infection Administration-Capsule Prescription/OTC-Prescription Dosage- 500 mg 1 day, then 250 mg for 2 -5 d Contraindications- Documented hypersensitivity Common side effects-Rash, nausea, abdominal pain, diarrhoea Unusual but important side effects-Acute allergic reaction and anaphylaxis Drug interactions- Warfarin, macrolides, fluconazole, efavirenz Monitoring- Clinical efficacy Dentistry Explorer

Intravenous Antibiotics Vancomycin HCL Imipenem/cilastatin Mechanism of action : • Imipenem acts as an antimicrobial through the inhibition of cell wall synthesis of various gram-positive and gram-negative bacteria. This inhibition of cell wall synthesis in gram-negative bateria is attained by binding to pencillin binding proteins (PBPs). Dentistry Explorer

Intravenous Antibiotics Generic name-Vancomycin HCL Brand name-VANCOGEN, VANCOLED Indications-Bacterial infection Administration- IV Prescription/OTC-Prescription Dosage-500 mg IV b. d. Contraindications- Documented hypersensitivity, impaired renal function Common side effects-Hypotension, fever, nausea, chills, eosinophilia, rash Drug interactions-Cidofovir, clofarabine, gallium nitrate Monitoring- Efficacy, serum levels of vancomycin Dentistry Explorer

Intravenous Antibiotics Generic name- Imipenem/cilastatin Brand name- CILASPENE, CIMISPECT Indications- Bacterial infection Administration- IM or IV Prescription/OTC-Prescription Dosage- 250 -1000 mg t. d. s. Contraindications-Documented hypersensitivity Common side effects-Thrombocytosis, diarrhea, rash, phleblitis, elevated liver function tests, elevated BUN and creatinine Drug interactions-Ganciclovir Monitoring- Efficacy, renal and hepatic function Dentistry Explorer

Prophylactic Regimens of Antibiotics against Infective Endocarditis for a Dental Procedure (1955 American Heart Association) Situation Agent Regimen-Single dose 30 -60 minutes before procedure Oral Amoxicillin Adults 2 gm Children 50 mg/kg Unable to take oral medication Ampicillin or cefazolin or ceftriaxone 2 g IM or IV 1 g IM or IV 50 mg/kg IM or IV Allergic to penicillins or ampicillin Oral Cephalexin or clindamycin 2 g 600 mg 50 m/kg 20 mg/kg 15 mg/kg Allergic to penicillins or ampicillin and unable to take oral medication Cefazolin or ceftriaxone Clindamycin phosphate 1 g IM or IM 50 mg/kg IM or IV 600 mg IM or IV 20 mg /kg IM or IV Azithromycin or clarithromycin Dentistry Explorer

Immunomodulators 1. Immunosuppressants 2. Immunostimulants Dentistry Explorer

Immunosuppressants • • Glucocorticoids Calcineurin Inhibitor a) Cyclosporine b) Tacrolimus Antiproliferative/ antimetabolic agent a) Sirolimus b) Evorolimus c) Azathioprine d) Mycophenolate Mofetil e) Methotrexate f) Cyclophosphamide Biologic ( Antibodies) a) Antithymocyte Globulin b) Monoclonal Antibodies c) Daclizumab d) Infliximab Colchicine Pentoxyfylline Nicotinamide Dentistry Explorer

Corticosteroids • Beclomethasone • Betamethasone • Clobetasol • • • Halobetasol Flucinonide Prednisolone Triamcinolone Dexamethasone Dentistry Explorer

Corticosteroids Antiinflammatory and Immunosuppressant actions Mechanism of action : • Glucocorticoids cause their effects by binding to the glucocorticoid receptor (GR). • The activated GR complex in turn up-regulates the expression of anti-inflammatory proteins in the nucleus (a process known as transactivation) and represses the expression of pro-inflammatory proteins in the cytosol by preventing the translocation of other transcription factors from the cytosol into the nucleus (transrepression). Dentistry Explorer

Topical corticosteroids Generic name-Beclomethasone Brand name- BECLATE INHALER, BECORIDE Indication- Severe recurrent aphthous stomatitis - Behcet’s syndrome - Pemphigus Vulgaris - Pemphigoid Administration- Metered inhaler spray topically to mucosal lesions Prescription / OTC- Prescription Dosage- 50 -100 micro g sprayed b. i. d. onto oral lesion until Dentistry Explorer symptom resolves

Beclomethasone contd… Contraindication- Untreated infections Common side effects- Oral candidiasis Unusual but important side effects- Adrenal suppression if doses exceeded Drug Interactions- Unusual with topical preparations Monitoring- Monitor if superinfection, especially candidiasis Dentistry Explorer

Topical corticosteroids Generic name- Betamethasone Brand name- BETNESOL, BETACORTRIL Indications- Severe recurrent aphthous stomatitis - Behcet’s syndrome - Pemphigus Vulgaris - Pemphigoid Administration- Topical intraoral cream or gel - soluble tablets as a mouthwash Prescription / OTC- Prescription Dosage- 0. 1 % cream or 0. 05 % gel applied thinly b. i. d. - 0. 5 mg 2 -4 times daily as a mouthwash Dentistry Explorer

Topical corticosteroids Generic name- Clobetasol Brand name- EUMOSON Indication- Severe recurrent aphthous stomatitis - Behcet’s syndrome - Pemphigus Vulgaris - Pemphigoid Administration- Topical intraoral cream or gel Prescription / OTC- Prescription Dosage- 0. 05 % cream or gel apply thinly b. i. d. Dentistry Explorer

Topical corticosteroids Generic name- Flucinonide Brand name- FLUCORT Indication- Severe recurrent aphthous stomatitis - Behcet’s syndrome - Pemphigus Vulgaris - Pemphigoid Administration- Topical intraoral cream Prescription / OTC- Prescription Dosage-0. 05 % cream applied thinly b. i. d. Dentistry Explorer

Betamethasone , Clobetasol , Flucinonide contd… Contraindication- Untreated infections Common side effects- Oral candidiasis Unusual but important side effects- Adrenal suppression if doses exceeded Drug Interactions- Unusual with topical preparations Monitoring- Monitor if superinfection, especially candidiasis Dentistry Explorer

Injectable corticosteroids Generic name- Triamcinolone Brand name- KENACORT, TRICORT Indication- Severe recurrent aphthous stomatitis - Major aphthous stomatitis - Erosive lichen planus Administration- Intralesional injection Prescription / OTC- Prescription Dosage-10 mg/ml - Inject 0. 1 cc/ 1 cm lesion Dentistry Explorer

Injectable corticosteroids Generic name- Dexamethasone Brand name- DECADRON, DEXONA Indication- Severe recurrent aphthous stomatitis - Major aphthous stomatitis - Erosive lichen planus Administration- i. v/i. m Prescription / OTC- Prescription Dosage- 4 mg/ml - Inject 0. 1 cc/ 1 cm lesion Dentistry Explorer

Triamcinolone , Dexamethasone contd… Contraindication- Hypersensitivity to corticosteriods, - Systemic fungal infection - Live vaccines - Active tuberculosis Common side effects- Candidiasis, hyperglycemia Unusual but important side effects- Peptic ulceration - Osteoporosis - Impaired wound healing - Mucosal atrophy Drug Interactions- Increased insulin requirement Monitoring- Blood pressure - Bone density before and during prolonged treatment Dentistry Explorer

Systemic corticosteroids Generic name- Prednisolone Brand name- DELTACORTRIL, HOSTACORTIN Indication - Severe recurrent aphthous stomatitis - Behcet’s syndrome - Pemphigus vulgaris - Erythema multiforme Administration- Tablets Prescription / OTC- Prescription Dentistry Explorer

Prednisolone contd… Dosage - 30 -40 mg daily after breakfast for 4 -5 days - 1 -2 mg/kg/d after breakfast until disease controlled - 1 -2 mg/kg/d, then maintenance of 2. 5 – 15 mg daily - 20 -40 mg daily for 7 -10 d at onset of lesions or until lesions resolve - 60 mg daily for 2 d, 50 mg daily for 2 d, 40 mg daily for 2 d, 30 mg daily for 2 d, 10 mg daily for 2 d Contraindication - Hypersensitivity to corticosteroids - Systemic infection ( unless specific antimicrobial therapy given ) - Peptic disease ( unless proton pump inhibitor given ) - Live vaccines Dentistry Explorer

Prednisolone contd… Common side effects- Dyspepsia - Candidiasis - Myopathy - Osteoporosis - Adrenal suppression - Cushing’s syndrome - Euphoria - Depression Unusual but important side effects- Peptic ulceration with perforation - Cushingoid side effects increasingly likely with doses above 7. 5 mg daily Dentistry Explorer

Prednisolone contd… Drug Interactions- Avoid live vaccines - Increased risk of GI ulceration and bleeding with aspirin and NSAIDS - Increased insulin and oral hypoglycemic requirements in diabetes mellitus - Decreased response to warfarin, potentiated by ketoconazole Monitoring- Blood presure - Bone density before and during prolonged treatment - HPA axis suppression Dentistry Explorer

Azathioprine Immunosuppressant Mechanism of action : • Azathioprine is a DNA synthesis inhibitor, as it is converted to a purine analogue inhibiting the proliferation of cells, especially lymphocytes. It is an effective drug used alone in certain autoimmune diseases, or in combination with other immunosuppressants in organ transplantation. Dentistry Explorer

Azathioprine Generic name- Azathioprine Brand name- IMURAN, TRANSIMUNE Indication - Severe recurrent aphthous stomatitis - Behcet’s syndrome - pemphigus vulgaris - Pemphigoid - Erythema multiforme Administration- Tablets Prescription / OTC- Prescription Dosage – 1 -3 mg/kg/d usually combined with systemic Corticosteriods Dentistry Explorer

Azathioprine contd… Contraindication – Hypersensitivity to Azathioprine, Pregnancy or hope to become pregnant, Breast feeding, very low or absent TPMT levels, Concurrent Allopurinol treatment, Concurrent malignant disease, Renal or Hepatic insufficiency, Live vaccines Common side effects- Hypersensitivity reactions, Nausea, vomiting, Liver impairment, Susceptibility to infections Unusual but important side effects- Pancreatitis Drug Interactions- Allopurinol Monitoring - TPMT activity before commencing treatment - Blood tests for signs of myelosuppression - Liver function Dentistry Explorer

Cyclophosphamide Immunosuppressant Mechanism of action : • The main effect of cyclophosphamide is due to its metabolite phosphoramide mustard. This metabolite is only formed in cells that have low levels of ALDH. • Phosphoramide mustard forms DNA crosslinks between (interstrand crosslinkages) and within (intrastrand crosslinkages) DNA strands at guanine N-7 positions. This is irreversible and leads to cell death. Dentistry Explorer

Cyclophosphamide Generic name-Cyclophosphamide Brand name- ENDOXAN, CYCLOXAN Indication - Pemphigus vulgaris - Pemphigoid - Erythema multiforme Administration- Tablets Prescription / OTC- Prescription Dosage – 1 -1. 5 mg/kg/d Contraindication – Porphyria, Pregnancy, Breast-feeding Common side effects- Thinning hair, Darkened skin, Blistering skin, Loss of appetite/weight Unusual but important side effects- Hemorrhagic cyctitis Drug Interactions- Increased absorption of Phenytoin, Clozapine, Cytotoxics, Suxamethonium Monitoring- Blood count, Liver function Dentistry Explorer

Colchicine Suppresses inflammation Mechanism of action : (1) a reduction in lactic acid production by leukocytes, which results in a decrease in uric acid deposition, and (2) a reduction in phagocytosis, with abatement of the inflammatory response. Dentistry Explorer

Colchicine Generic name- Colchicine Brand name- COLCHINDON Indication - Severe recurrent aphthous stomatitis - Behcet’s syndrome Administration- Tablets Prescription / OTC- Prescription Dosage- 500 micro gm t. i. d. Contraindication- Pregnancy Common side effects- Nausea , Vomiting, Abdominal pain Unusual but important side effects- Anorexia Drug Interactions- Clarithromycin, Erythromycin, Cyclosporine Monitoring- Blood test for Agranulocytosis , aplastic anemia Dentistry Explorer

Immunostimulants • • • Levamisole Thalidomide Dapsone BCG Cytokines- Interferons - Interleukin-2 Dentistry Explorer

Thalidomide Immunostimulant action Anti-inflammatory action Dentistry Explorer

Thalidomide Generic name-Thalidomide Brand name- THALODA, TALIMYDE Indication - Severe recurrent aphthous stomatitis - Major aphthous stomatitis unresponsive to otherapy - Behcet’s syndrome - Erythema multiforme Administration- Tablets Prescription / OTC- Prescribed only by those registered in the STEPS program Dosage – 100 -300 mg daily with water at bedtime Dentistry Explorer

Thalidomide contd… Contraindication – Pregnancy, Unprotected intercourse if risk of pregnancy Common side effects- Severe birth defects, Peripheral neuropathy, Drowsiness, Malaise, Dizziness, Headache, Rash Unusual but important side effects-Thrombotic events, Neutropenia, Increased HIV viral load Drug Interactions- Barbiturates, Alcohol, Chlorpromazine, Reserpine Monitoring- Baseline nerve conduction studies and after every 10 gm of drug - Monthly pregnancy testing in women - Follow STEPS program Dentistry Explorer

Dapsone Mechanism of action : • It is structural analogue to PABA (Para amino benzoic acid) and PABA is used by bacteria to synthesise Folic acid. • Inhibit bacterial folate synthesis which inturn inhibit various essential metabolic reaction of the mirobes. Dentistry Explorer

Dapsone Generic name- Dapsone Brand name- DAPSONE Indication - Pemphigus vulgaris - Pemphigoid - Erythema multiforme -Behchet disease Administration- Tablets Prescription / OTC- Prescription Dosage – 1 -2 mg/kg/d Contraindication – Porphyria, Anemia, Glucose-6 -Phosphate dehydrogenase Deficiency (requires reduced dose), Pregnancy, Breast-feeding Common side effects- Hemolysis, Methemaglobinemia, Agranulocytosis, Skin reactions Unusual but important side effects- Dapsone syndrome (rash, fever, eosinophilia) Drug Interactions- Plasma levels increase with Trimethoprim Monitoring-Measure G 6 PD levels before treatment Dentistry Explorer

Pentoxyfylline Phosphodiesterase inhibitor Mechanism of action : • It has shown to increase blood flow in ischaemic areas by reducing whole blood viscosity and by improving flexibility of RBCs. Dentistry Explorer

Pentoxyfylline Generic name- Pentoxyfylline Brand name- TRENTAL, FLEXITAL Indication - Severe recurrent aphthous stomatitis - Behcet’s syndrome -Transient ischaemic attack Administration- Tablets Prescription / OTC- Prescription Dosage- 400 mg t. i. d. Contraindication-Cerebral hemorrhage, Myocardial infarction, Pregnancy , Breast feeding, Porphyria Common side effects- Gastrointestinal disturbances, Dizziness, Allergic reactions Unusual but important side effects- Decreased blood pressure, Patients taking Antihypertensives Drug Interactions-Analgesics, Theophylline Monitoring- Blood pressure in patients taking Antihypertensives Dentistry Explorer

Nicotinamide Generic name- Nicotinamide Brand name- NICOTINAMIDE Indication – Pemphigoid Administration- Tablets Prescription / OTC- Prescription Dosage – 1. 5 -2 gm o. d. with Tetracycline Contraindication – Hypersensitivity to Nicotinamide, Pregnancy, Breastfeeding • Common side effects- Nausea, Bloating, Flatulence, Dizziness • • Unusual but important side effects- Hepatic damage, Avoid high dose in patient with Diabetes, Liver disease • Drug Interactions- Decreased clearance of Carbamazeprine and Prednisone • Monitoring-Hepatic function Dentistry Explorer

Antiviral Drugs • • • Acyclovir Penicyclovir Docosanol Valacyclovir Famcyclovir Dentistry Explorer

Antiviral Drugs Anti-Herpes virus Mechanism of action : • Inhibitor of viral DNA polymerase. Dentistry Explorer

Antiviral drugs Generic name: Acyclovir Brand name: ZOVIRAX, CYCLOVIR Indications: Herpes labialis, herpes zoster, mucocutaneous HSV, varicella-zoster, salivary viral infection Administration: Tablets , Cream, Ointment Prescription/ OTC: Prescription Dosage: RHL: 400 mg q. i. d. for 5 d HZV: 800 mg 6 times /d for 7 -10 d Mucocutaneous: 400 mg q. i. d. for 7 -14 d HSV prevention: 200 mg t. i. d. or 400 mg bid for 7 -10 d Salivary viral infection: 400 mg q. i. d. for 7 d 5% cream, q. i. d. for 4 d, 5 % Ointment , q. i. d. for 4 d Contraindications: Hypersensitivity to acyclovir, valacyclovir Common side effects: Lightheadedness; anorexia; hives; itching; rash; nausea; vomiting; increased liver enzymes; BUN, creatinine Unusual but important side effects: Abdominal pain, erytheme multiforme, toxic epidermal necrolysis Dentistry Explorer Drug interactions: Zidovudine, probenecid

Antiviral drugs Generic name: Famcyclovir Brand name: FAMVIR Indications : Herpes zoster, recurrent HSV in immunocompromised patients Administration: Tablets Prescription/ OTC: Prescription Dosage: HZV: 500 mg t. i. d. for 7 d Recurrent HSV in immunocompromised patients: 125 mg b. i. d. for 5 d Contraindications: Hypersensitivity to famcyclovir Common side effects: Headache, diarrhoea, abdominal pain, nausea Unusual but important side effects: Arthralgia, rigor, upper respiratory infection Drug interactions: Cimetidine, digoxin, probenecid, theophylline Dentistry Explorer Monitoring: Complete Blood Count

Antifungal Drugs • • • Nystatin Clotrimazole Ketoconazole Fluconazole Itraconazole Dentistry Explorer

Antifungal Mechanism of action : • Inhibits the fungal cytochrome P 450 enzyme 14αdemethylase. This inhibition prevents the conversion of lanosterol to ergosterol, an essential component of the fungal cytoplasmic membrane, and subsequent accumulation of 14α-methyl sterols. Dentistry Explorer

Topical antifungal drugs Generic name: Nystatin Brand name: NYSTIN, MYCOSTATIN Indications: Oropharyngeal candidiasis Administration: Oral suspension, powder, cream, lozenge Prescription/ OTC: prescription Dosage: Oral suspension (100, 000 U/ml): 400, 000 -600, 000 units 4 -5 times/d(swish and swallow) Troche (200, 000 U): 200, 000 -400, 000 U 4 -5 times/d 100, 000 U/g cream and oinment: Apply to affected area 4 -5 times/d Powder (50 million U): Sprinkle on tissue contact area of denture Contraindications: Hypersensitivity to nystatin Common side effects: Nausea, vomiting, diarrhoea, stomach pain, contact dermatitis Unusual but important side effects: Hypersensitivity Drug interactions: None Monitoring: Liver function test Dentistry Explorer

Topical antifungal drugs Generic name: Clotrimazole Brand name: SURFAZ, CLOTRIN Indications: Oropharengeal candidiasis Administration: Troche Prescription/ OTC: Prescription and OTC Dosage: 10 mg troche: dissolve slowly over 15 -30 min 5 times daily: apply to affected area b. i. d. for 7 d cream can be applied to the tissue contact areas of the denture Contraindications: Hypersensitivity to clotrimazole Common side effects: Abnormal liver function test, nausea, vomiting, local mild burning, irritation, stinging Unusual but important side effects: Avoid contact with eyes Drug interactions: None Monitoring: Liver function test Dentistry Explorer

Systemic antifungal drugs Generic name: Fluconazole Brand name: SYSCAN, ZOCON Indications: Oral and esophageal candidiasis Administration: Capsule, powder Prescription/ OTC: Prescription Dosage: Tablets: 200 mg on day 1 then 100 mg daily for 7 -14 d Powder for oral suspension (10 mg/ml); dosing is the same as for tablet Contraindications: Hypersensitivity to azole drugs, left ventricular dysfunction, congestive heart failure Common side effects: Headache, nausea, vomiting, abdominal pain, rash, diarrhoea, taste perversion, dyspepsia Unusual but important side effects: Anaphylactic reactions, liver failure Drug interactions: Cisapride Dentistry Explorer Monitoring: Liver and renal function test, potassium

Systemic antifungal drugs Generic name: Itraconazole Brand name: SPORONAX, CANDITRAL Indications: Oral and esophageal candidiasis Administration: Solution Prescription/ OTC: Prescription Dosage: Solution (10 mg/ml); 100 -200 mg/10 ml once a day for 1 -2 wk; if refractory to fluconazole: 100 mg b. d. Contraindications: Hypersensitivity to azole drugs, left ventricular dysfunction, congestive heart failure Common side effects: Nausea, edema, hypertension, headache, fatigue, malaise, fever, dizziness, rash, pruritis, decreased libido, hyperkalemia, abdominal pain, anorexia, vomiting, diarrhoea, increased liver enzymes, hepatitis Unusual but important side effects: Adrenal suppression, allergic reactions, arrhythmia, congestive heart failure, Stevens- Johnson syndrome Drug interactions: Inhibits certain cytochrome P-450 substrates Monitoring: Liver function tests after 1 month of treatment Dentistry Explorer

Systemic antifungal drugs Generic name: Ketoconazole Brand name: NRAL, KETOVATE Indications: Oral and esophageal candidiasis Administration: Cream , Tablets Prescription/ OTC: Prescription Dosage: Rub gently into the affected area 1 -2 times daily 200 -400 mg/d as single dose for 7 -14 d Contraindications: Hypersensitivity to ketoconazole; administration with ergot derivatives or cisapride Common side effects: Pruritis, nausea, vomiting, abdominal pain Unusual but important side effects: Bulging fontanelles, chills, depression, diarrhoea, dizziness, fever, gynecomastia, headaches, hemolytic anemia, hepatotoxicity, impotence, leukopenia, photophobia, somnolence, thrombocytopenia Drug interactions: Inhibits certain cytochrome P-450 substrates Monitoring: Liver function tests Dentistry Explorer

Sialogogues • Pilocarpine hydrochloride • Cevimeline hydrochloride Dentistry Explorer

Sialogogues Cholinergic agonist Mechanism of action : • Pilocarpine is a cholinergic parasympathomimetic agent. It increase secretion by the exocrine glands, and produces contraction of the iris sphincter muscle and ciliary muscle (when given topically to the eyes) by mainly stimulating muscarinic receptors. Dentistry Explorer

Pilocarpine hydrochloride Generic name- Pilocarpine hydrochloride Brand name-CARPIN Indication - 1. Symptoms of dry mouth from salivary gland hypofunction caused by radiotherapy for cancer of head and neck. 2. Symptoms of dry mouth in patients with Sjögren’s syndrome Administration- Tablets Prescription / OTC- Prescription Dosage – 5 mg t. i. d. adjusted to theraputic response and tolerability. Usual dose range is 15 -30 mg daily, not to exceed 10 mg/dose. 12 weeks of uninterrupted therapy is recommended. Dentistry Explorer

Cevimeline hydrochloride Generic name- Cevimeline hydrochloride Brand name- ALBAQUIN Indication - 1. Symptoms of dry mouth from salivary gland hypofunction caused by radiotherapy for cancer of head and neck. 2. Symptoms of dry mouth in patients with Sjögren’s syndrome Administration- Tablets Prescription / OTC- Prescription Dosage – 30 mg t. i. d. Dentistry Explorer

Pilocarpine hydrochloride , Cevimeline hydrochloride contd… Contraindication – Uncontrolled asthma, hypersensitivity to drug, acute iritis, narrow-angle (angle closure) glaucoma, acute hepatic impairment. Common side effects- Sweating, nausea, rhinitis, diarrhoea, chills, flushing, urinary frequency, dizziness, asthenia, headache, dyspepsia, lacrimation Unusual but important side effects- Visual disturbances, atrioventricular block, biliary contractions and obstruction, precipitation of renal colic Drug Interactions- Beta- adrenergic antagonists: use with caution All drugs with parasympathomimetc effects Drugs intended to cause anticholinergic effects Monitoring- Monitor for significant side effects. Dentistry Explorer

Amifostine Mechanism of action : • Accelerated DNA repair, induction of cellular hypoxia, inhibition of apoptosis, alteration of gene expression and modification of enzyme activity. Dentistry Explorer

Amifostine Generic name- Amifostine Brand name-AMFOS, AMIPHOS Indication -1. To reduce the incidence of moderate to severe xerostomia in patients undergoing postoperative radiation treatment for head and neck cancer, where the radiation port includes a substantial portion of the parotid glands. 2. Can be used off-label to reduce the incidence of moderate to severe xerostomia in patients undergoing radiation treatment of head and neck cancer in combination with chemotherapy Administration- Tablets Prescription / OTC- Prescription Dentistry Explorer

Amifostine contd… Dosage – 200 mg/m 2 administered once daily as a 3 min IV infusion, starting 15 -30 min prior to radiation treatment. - 500 mg reconstituted with 2. 5 ml normal saline given subcutaneously in one or two injections, once daily, 15 min prior to radiation treatment. Contraindication – Sensitivity to aminothiol compounds, hypotension, dehydration Common side effects- Transient hypotension, nausea, vomiting, flushing, chills, fever, dizziness, somnolence, hiccups, sneezing Unusual but important side effects- Acute allergic reaction and anaphylaxis, hypocalcemia, shortterm reversible loss of consciousness Dentistry Explorer

Amifostine contd… Drug Interactions- amifostine should be used with caution in patients taking antihypertensive drugs or other drugs that could cause or potentiate hypotension. Monitoring- Adequate hydration prior to administration -Blood pressure during and after administration -Nausea and vomiting- antiemetic medication should be given prior to and in conjunction with amifostine (oral 5 HT 3 receptor antagonists) -Serum calcium levels in patients at risk of hypocalcaemia (nephritic syndrome) Dentistry Explorer

Glycopyrrolate Synthetic Antisecretory-antispasmodic Mechanism of action : Glycopyrrolate binds competitively to the muscarinic acetylcholine receptor. it inhibits the action of acetylcholine on structures innervated by postganglionic cholinergic nerves and on smooth muscles that respond to acetylcholine but lack cholinergic innervation. These peripheral cholinergic receptors are present in the autonomic effector cells of smooth muscle, cardiac muscle, the sinoatrial node, the atrioventricular node, exocrine glands and, to a limited degree, in the autonomic ganglia. Thus, it diminishes the volume and free acidity of gastric secretions and controls excessive pharyngeal, tracheal, and bronchial secretions. Dentistry Explorer

Glycopyrrolate Generic name- Glycopyrrolate Brand name- GLYCO-P, PYROLATE Indication – Sialorrhea (drooling) Administration- Tablets Prescription / OTC- Prescription Dosage – 1 mg 30 -60 mins before dental procedures 1 mg q. i. d. as needed to inhibit drooling Dentistry Explorer

Atropine Natural alkaloid (Anticholinergic) Mechanism of action : • It antagonizes the muscarine-like actions of acetylcholine and other choline esters. Dentistry Explorer

Atropine Generic name- Atropine Brand name- ATROPINE SULPHATE Indication – Sialorrhea Administration- Tablets Prescription / OTC- Prescription Dosage – 0. 4 mg 30 -60 min before dental procedures 0. 4 mg q. i. d. as needed to inhibit drooling Dentistry Explorer

Glycopyrrolate, Atropine contd… Contraindication – Glaucoma, chronic constipation, ulcerative colitis, acute hepatic impairment Common side effects- dry skin, constipation, dry throat, xerostomia, dry nose, dysphagia, drowiness Unusual but important side effects- Fast/ irregular heart beat, heat stroke in hot weather, difficulty urinating Drug Interactions- increased toxicity with antacids, effects of other anticholinergic agents may be increased with these drugs Monitoring- monitor for significant side effects Dentistry Explorer

Anticonvulsants • • • Carbamazepine Gabapentin Pregabalin Lamotrigine Oxcarbazepine Topirimate Dentistry Explorer

Anticonvulsants Mechanism of action : • Voltage-gated sodium channels are the molecular pores that allow brain cells (neurons) to generate action potentials, the electrical events that allow neurons to communicate over long distances. After the sodium channels open to start the action potential, they inactivate, essentially closing the channel. Carbamazepine stabilizes the inactivated state of sodium channels, meaning that fewer of these channels are available to subsequently open, making brain cells less excitable (less likely to fire). Carbamazepine has also been shown to potentiate GABA receptors made up of alpha 1, beta 2, gamma 2 subunits. Dentistry Explorer

Anticonvulsants Generic pain- Carbamazepine Brand name- TEGRETOL, MAZETOL Indications- Cranial neuralgias, traumatic neuropathy, neuropathic pain of undetermined origin, less commonly for stomatodynia (burning mouth) Administration-Tablets Suspension Prescription/OTC- Prescription Dosage- Tablets: 200 -600 mg b. i. d. Slow escalation Suspension: 100 mg/5 cc; dosed as needed 200600 mg b. i. d. Dentistry Explorer

Carbamazepine contd… Contraindications- Allergy, hypersensitivity to TCAs, recent MAO inhibitor use, marrow depression, impaired liver or renal function, cardiac disease Common side effects- Dizziness, drowsiness, nausea/vomiting, blurred vision, allergic rash, cognitive impairment, elevated liver enzymes, hyponatremia, ataxia Unusual but important side effects- Withdrawal seizures, arrythmias, syncope, anemia, pancytopenia, hepatits, hyponatremia, Stevens. Johnsons syndrome(rare), erythema multiforme(rare) Drug interactions- CNS depressants: additive sedation Azole antifungals Doxycycline Monitoring- Drug levels, Complete Blood Count, metabolic panel, liver Dentistry Explorer function

Anticonvulsants Generic name- Gabapentin Brand name- NEURONTIN Indications- Cranial neuralgias, traumatic neuropathy, neuropathic pain of undetermined origin, less commonly for stomatodynia (burning mouth) Administration-Capsule Suspension Prescription/OTC- Prescription Dosage- Tablets: 300 -1200 mg t. i. d. Slow escalation Solution: 250 mg/5 ml; dosed as needed 200 -600 mg b. i. d. Dentistry Explorer

Gabapentin contd… Contraindications- Allergy, congestive heart failure, impaired renal function, careful use in elderly Common side effects- Dizziness, somnolence, ataxia, peripheral edema, weight gain, blurred vision, cognitive impairment, dry mouth, tremor, headache, constipation, neuropathy, decreased platelets Unusual but important side effects- Severe skin reactions, CHF exacerbation, severe myalgia, thrombocytopenia Drug interactions- CNS depressants; additive sedation Monitoring- Drug levels , Complete Blood Count Dentistry Explorer

Anticonvulsants Generic name- Lamotrigine Brand name- LAMITOR, LAMIDUS Indications- Cranial neuralgias, traumatic neuropathy, neuropathic pain of undetermined origin, less commonly for stomatodynia(burning mouth) Administration- tablets Prescription- Prescription/OTC Dosage- 50 -200 mg b. i. d. slow escalation Dentistry Explorer

Anticonvulsants Generic name- Topirimate Brand name- TOPEX Indications- Cranial neuralgias, traumatic neuropathy, neuropathic pain of undetermined origin, less commonly for stomatodynia (burning mouth) Administration- Tablets Prescription/OTC- Prescription Dosage-50 -100 mg b. i. d. slow escalation Dentistry Explorer

Lamotrigine , Topirimate contd… Contraindications- Allergy, impaired liver or renal function Common side effects- Metabolic acidosis, dizziness, somnolence, fatigue, nervousness, paresthesias, cognitive impairment, ataxia, anorexia, nausea, depression, diarrhea, mood disturbances, tremor, taste changes, weight loss, insomnia Unusual but important side effects- Metabolic acidosis, osteomalacia, osteoporosis, growth suppression(pediatrics), diabetes mellitus, leukopenia, anemia, psychosis, skin reaction, hepatotoxicity, fatal pancreatitis, deep vein thrombosis, pulmonary embolism Drug interactions- CNS depressants(additive sedation), oral contraceptives, carbamazepine, azole antifungals Monitoring-Drug level, Complete Blood Count, metabolic panel Dentistry Explorer

Antidepressant and Anxiolytic • • • Amitriptyline Nortriptyline Imipramine Clonazepam Doxepin Duloxetin Dentistry Explorer

Antidepressant and Anxiolytic Mechanism of action : • Inhibits the membrane pump mechanism responsible for uptake of norepinephrine and serotonin in adrenergic and serotonergic neurons. • Exerts its action by binding to the benzodiazepine site of the GABA receptors, which causes an enhancement of the electric effect of GABA binding on neurons, resulting in an increased influx of chloride ions into the neurons. This results in an inhibition of synaptic transmission across the central nervous system Dentistry Explorer

Antidepressant and Anxiolytic Generic name- Amitriptyline Brand name- AMLINE, SAROTENA Indications-Adjuvant for cranial neuralgias, primary for generalized neuropathic pain, stomatodynia(burning mouth) Administration- Tablets Prescription/OTC- Prescription Dosage-10 -100 mg h. s. Dentistry Explorer

Antidepressant and Anxiolytic Generic name-Nortriptyline Brand name- SENSIVAL, PRIMOX Indications-Adjuvant for cranial neuralgias, primary for generalized neuropathic pain, stomatodynia(burning mouth) Administration- Tablets Prescription/OTC- Prescription Dosage- 10 -75 mg h. s. Dentistry Explorer

Antidepressant and Anxiolytic Generic name- Imipramine Brand name- DEPSONIL, ANTIDEP Indications-Adjuvant for cranial neuralgias, primary for generalized neuropathic pain, stomatodynia(burning mouth) Administration-Tablets, Capsule Prescription/OTC- prescription Dosage- 10 -50 mg h. s. Dentistry Explorer

• Contraindications- Allergy, recent MAO inhibitor use, myocardial infarction, cardiovascular disease, gastrointestinal/genitourinary obstruction, urinary retention, narrow-angle glaucoma, seizure disorder, diabetes mellitus, asthma, impaired liver function, alcohol abuse, suicide risk, elderly patients • Common side effects- Drowsiness, dry mouth, dizziness, constipation, blurred vision, palpitations, incoordination, increased appetite, nausea/vomiting, sweating, cognitive impairment, weakness, restlessness, insomnia, anxiety/agitation, urinary retention, rash, weight gain, libido changes/impotence, tremor, hypo/hyperglycemia, paresthesias, photosensitivity Dentistry Explorer

Unusual but important side effects- Orthostatic hypotension, hypertension, syncope, arrythmia, AV block, myocardial infarction, stroke, seizures, tardive dyskinesia(rare), pancytopenia, hallucinations, suicidality, hepatitis(rare), angioedema, hyperthermia Drug interactions-CNS depressants: additive depression Monitoring- Drug level, Complete Blood Count, metabolic panel, Electrocardiography Dentistry Explorer

Antidepressant and Anxiolytic Medications Generic name- Clonazepam Brand name-LONZEP, CLONAPAX Indications-Adjuvant for cranial neuralgias, primary medication for generalized neuropathic pain, stomatodynia(burning mouth) Administration-Tablets Transmucosal water Prescription/OTC-Prescription Dosage-Tablets: 0. 5 -4 mg h. s. or divided during day Water: 0. 25 mg q. i. d. s. o. s. Dentistry Explorer

Clonazepam contd… Contraindications-Allergy, impaired liver function, impaired respiratory function Common side effects-Withdrawal syndrome, drowsiness, ataxia, cognitive impairment, constipation, diarrhea, dry mouth, headache, sleep changes, hypotension, rash Unusual but important side effects- Respiratory depression, neutropenia, hepatotoxicity, seizures Drug interactions-CNS depressant: additive depression; azole antifungals; carbamazepine; erythromycin; opiates; pregablin Monitoring-Complete Blood Count, metabolic panel Dentistry Explorer

Antidepressant and Anxiolytic Medications Generic name- Doxepin Brand name-SPECTRA, DOXIN Indications-Adjuvant for cranial neuralgias, primary medication for generalized neuropathic pain, stomatodynia(burning mouth) Administration-Tablets Topical Prescription/OTC-Prescriptions Dosage-10 -50 mg h. s. Contraindications- Allergy, recent MAO inhibitor use, myocardial infarction, cardiovascular disease, gastrointestinal/genitourinary obstruction, urinary retention, narrow-angle glaucoma, seizure disorder, diabetes mellitus, asthma, impaired liver function, alcohol abuse, suicide risk, elderly patient Dentistry Explorer

Doxepin contd… Common side effects- Drowsiness, dry mouth, dizziness, constipation, blurred vision, palpitations, incoordination, increased appetite, nausea/vomiting, sweating, cognitive impairment, weakness, restlessness, insomnia, anxiety/agitation, urinary retention, rash, weight gain, libido changes/impotence, tremor, hypo-/hyperglycemia, paresthesias, photosensitivity Unusual but important side effects- Orthostatic hypotension, hypertension, syncope, arrythmia, AV block, myocardial infarction, stroke, seizures, tardive dyskinesia(rare), pancytopenia, hallucinations, suicidality, hepatitis(rare), angioedema, hyperthermia Drug interactions-CNS depressants: additive depression; carbamazepine: erythromycin; pregablin: tramadol Monitoring- Drug level, Complete Blood Count, metabolic panel, Electrocardiography Dentistry Explorer

Muscle Relaxant • • • Baclofen Cyclobenzaprine Carisoprodol Tizanidine Metaxalone Dentistry Explorer

Muscle Relaxant Mechanism of action : • produces its effects by modulating the GABA receptor. Dentistry Explorer

Muscle Relaxants Generic name-Baclofen Brand name-LIORESAL Indications-Myofascial pain with muscle tension component Administration-Tablets Prescription/OTC-Prescription Dosage-10 -20 mg b. i. d. for 3 months Contraindications-Allergy, impaired renal function, seizure, stroke, diabetes, elderly patients Common side effects-Drowsiness, dizziness, dry mouth, fatigue, hypotension, nausea, vomiting, nervousness, confusion, headache, rash, pruritis Unusual but important side effects-CNS and respiratory depression, ataxia, seizures, hallucinations Drug interactions-CNS depressants: additive depression Monitoring-None Dentistry Explorer

Muscle Relaxants Generic name-Carisoprodol Brand name-CARISOMA, SOMAFLAM Indications-Myofascial pain with muscle tension component Administration-Tablets Prescription/OTC-Prescription Dosage-350 mg t. i. d. /q. i. d. Contraindications-Allergy, impaired renal and liver function Common side effects- Drowsiness, dizziness, dry mouth, fatigue, hypotension, nausea, vomiting, nervousness, confusion, headache, rash, pruritis Unusual but important side effects-Erythema multiforme, anaphylaxis Drug interactions-CNS depressants: additive depression Monitoring-None Dentistry Explorer

Muscle Relaxants Generic name-Tizanidine Brand name-SIRDALUD, TIZAN Indications-Myofascial pain with muscle tension component Administration-Tablets Prescription/OTC-Prescription Dosage-8 mg t. d. s. / q. i. d. s. o. s. Contraindications-Allergy, impaired renal and liver function Common side effects- Drowsiness, dizziness, dry mouth, fatigue, hypotension, nausea, vomiting, nervousness, confusion, headache, rash, pruritis Unusual but important side effects-Hepatotoxicity, bradycardia, hypotension, hypertension Drug interactions-CNS depressants: additive depression, oral contraceptives Monitoring-Liver function Dentistry Explorer

Conclusion As in Oral Medicine we deal with the oral mucosal diseases, salivary gland disorders, facial pain syndromes and also provide dental care for patients with complicating medical disease, therefore it is essential to keep in mind the various drugs in terms of Mechanism of action , Generic name, Brand name , Indication , Administration , Prescription / OTC , Dosage , Duration , Contraindication , Common side effects , Unusual but important side effects , Drug interactions, Monitoring while writing a prescription for the diseases mentioned above. Dentistry Explorer

References : Burket’s Oral medicine -11 th Edition Martin S. Greenberg Michael Glick Jonathan A. Ship Essentials of Medical Pharmacology -5 th Edition KD Tripathi Oxford Handbook of Clinical Dentistry-5 th Edition Laura Mitchell David A. Mitchell with Lorna Mc. Caul Principles of Dental Pharmacology Naresh Kumar Khanna Dentistry Explorer

MCQs • Which one is correct way of prescribing a drug… A. B. C. D. Rx caps Amoxicillin 500 mg t. i. d. p. o. 1 week Rx caps Amoxicillin 500 mg po t. i. d. 1 week Rx Amoxicillin 500 mg caps t. i. d. p. o. 1 week Rx Amoxicillin 500 mg caps p. o t. i. d. 1 week Dentistry Explorer

Ans- B Dentistry Explorer

MCQs • Chlorhexidine wouthwash can be prescribed as…. . A. Chlorhexidine 0. 2 % B. Clorhexidine 0. 12 % C. Chlorhexidine 0. 1 % Dentistry Explorer

Ans- A Dentistry Explorer

MCQs • Amoxicillin for Intraoral Bacterial Manifestation for an adult is prescribed as… A. 250 mg t. d. s. B. 500 mg t. d. s. C. 250 mg b. d. D. 500 mg b. d. Dentistry Explorer

Ans- B Dentistry Explorer

MCQs • Drug used for reduction of Xerostomia in Patients Undergoing Head and Neck Radiotherapy for Cancer is… A. Pilocarpine hydrochloride B. Cevimeline hydrochloride C. Atropine D. Amifostine Dentistry Explorer

Ans- D Dentistry Explorer

Thank You Dentistry Explorer