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Drugs in Dentistry Haas 2013
Drugs in Dentistry Haas 2013
Analgesics
(Figure 1 - Management of Acute Postoperative Dental Pain in Adults)
Figure 1: Management of Acute Postoperative Dental Pain in Adults
Table 1: Analgesics for Orofacial Pain: Pediatric Doses
Table 2: Analgesics for Orofacial Pain: Adult Doses
Consider the following points in the use of analgesics:
Be aware of the contraindications and cautions for NSAIDs, including ASA (see also
individual product monographs and CPhA monographs as well as comprehensive drug
interaction references).
Avoid NSAIDs in patients with:
Avoid or use NSAIDs with caution, for the shortest possible time, in patients with:
Table 1 and Table 2 list common analgesics and corresponding pediatric and adult
doses recommended to treat orofacial pain.
Table 1: Analgesics for Orofacial Pain: Pediatric Doses (Printable Table)
Drug
Pediatric Dose
Daily Maximuma
Acetaminophen
65 mg/kg or 2600 mg
Codeine
3 mg/kgb
Ibuprofen
10 mg/kg Q68H po
40 mg/kg or 2400 mg
a.
b.
Adult Dose
Daily Maximuma
Nonopioids
Simple Analgesics
Acetaminophen
3251000 mg Q46H po
4000 mg
ASA
3251000 mg Q46H po
4000 mg
Celecoxib
400 mg
Diflunisal
1500 mg
Etodolac
200400 mg Q68H po
1200 mg
Floctafenine
200400 mg Q68H po
1200 mg
Flurbiprofen
50100 mg Q46H po
300 mg
Ibuprofen
400 mg Q46H po
2400 mg
Ketoprofen
2550 mg Q68H po
300 mg
Ketorolac
10 mg Q46H po
40 mg
Naproxen
1250 mg
Naproxen sodium
1375 mg
Codeine
3060 mg Q46H po
Oxycodone
510 mg Q46H po
NSAIDs
Opioidsc
a.
Anti-infectives6
Consider the following points when using antibiotics:
Amoxicillin
250500 mg TID po
Amoxicillin/clavulanate
Cephalexin
250500 mg QID po
Clarithromycin
250500 mg BID po
Clindamycin
150300 mg QID po
Doxycycline
Erythromycin
250500 mg QID po
Metronidazole
250500 mg TID po
Penicillin V
300600 mg QID po
Adult Dose
Immunocompetent Patients
Nystatin oral
suspension
Immunocompromised Patients
Nystatin oral
suspension
Fluconazole
Itraconazole
Ketoconazole
Endocarditis Prophylaxis8
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Table 5 lists cardiac conditions associated with the highest risk of adverse outcome
from infective endocarditis, for which antibacterial coverage is considered reasonable
for patients undergoing certain dental procedures.8
Table 5: Cardiac Conditions Associated with the Highest Risk of Adverse Outcome from
Endocarditis for which Prophylaxis with Dental Procedures is Reasonable(Printable
Table)
Prosthetic cardiac valve, or prosthetic material used for cardiac valve repair
Previous infective endocarditis
Congenital heart disease (CHD)a
Unrepaired cyanotic CHD, including palliative shunts and conduits
Completely repaired congenital heart defect with prosthetic material or
device, whether placed by surgery or by catheter intervention, during
the first 6 months after the procedure
Repaired CHD with residual defects at the site or adjacent to the site of a
prosthetic patch or prosthetic deviceb
Cardiac transplantation recipients who develop cardiac valvulopathy
a.
Except for conditions listed above, antibacterial prophylaxis is no longer recommended for any other
form of CHD.
b.
Drug
Pediatric Doseb
(3060 minutes before procedure)
Standard Regimen
Amoxicillin
2 g po
50 mg/kg po
2 g imc or iv
50 mg/kg imc or iv
1 g imc or iv
50 mg/kg imc or iv
1 g imc or iv
50 mg/kg imc or iv
or
Cefazolin
or
Ceftriaxone
Allergic to Penicillins
Clindamycin
600 mg po
20 mg/kg po
2 g po
50 mg/kg po
500 mg po
15 mg/kg po
500 mg po
15 mg/kg po
or
Cephalexind
,e
or
Clarithromycin
or
Azithromycin
600 mg imc or iv
20 mg/kg iv
1 g imc or iv
50 mg/kg imc or iv
1 g imc or iv
50 mg/kg imc or iv
or
Cefazoline
or
Ceftriaxonee
a.
b.
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The Canadian Dental Association (CDA) released a new position statement in 2013
regarding antibiotic prophylaxis for dental patients with total joint replacements.9
CDA states that:
routine antibiotic prophylaxis is not indicated for dental patients with total joint
replacements or with orthopedic pins, plates and screws.
In 2011 the American Dental Association (ADA) and American Academy of Orthopaedic
Surgeons (AAOS) conducted a systematic review that found no direct evidence to
suggest that dental procedures cause orthopedic implant infections. The new CDA
position is based on this evidence and differs from the ADA and AAOS clinical practice
guidelines.10 , 11
The Canadian statement also advises that:
patients should not be exposed to the adverse effects of antibiotics when there is
no evidence of benefit with the prophylactic use of these medications
patients should be in good oral health prior to having joint replacement surgery
and continue to maintain good oral hygiene and oral health following surgery
any patient experiencing orofacial infection should be treated to eradicate the
infection and prevent it from spreading.
Local Anesthetics
Potential Interactions with epinephrine or levonordefrin:13 Adding epinephrine
or levonordefrin to the local anesthetic formulation improves the depth and duration of
the local anesthetic block. However, exercise caution if a patient has a history of
significant cardiovascular disease or is concomitantly taking any of the following drugs:
In these cases, use the lowest effective dose of epinephrine and consider a maximum
of <40 g.14 The administration of levonordefrin is contraindicated in individuals taking
tricyclic antidepressants. For those with cardiovascular disease or taking nonselective
beta-blockers, use the lowest effective dose of levonordefrin and consider a maximum
of <200 g.14
Avoid epinephrine altogether in patients who have ingested cocaine within the
previous 24 hours, as there is increased risk of cardiac dysrhythmias and
increased blood pressure.
The dose of vasoconstrictor delivered per 1.8 mL dental cartridge is as follows:
1 cartridge of 1:200 000 epinephrine = 9 g
1 cartridge of 1:100 000 epinephrine = 18 g
1 cartridge of 1:50 000 epinephrine = 36 g
1 cartridge of 1:20 000 levonordefrin = 90 g.
Table 8: Maximum Recommended Doses of Local Anesthetics 1
Maximum Dose
(mg/kg)
Maximum no. of
Cartridgesa
10
13
6.6
11
Mepivacaine 3% plain
6.6
Prilocaine 4% plain
Drug
a.
b.
1.8 mL volume.
Not recommended for children.
Tooth
Pulp
Soft Tissue
Tooth
Pulp
Soft Tissue
60
170
90
220
40
340
240
440
60
170
85
190
Mepivacaine 2% with
levonordefrin1:20 000
50
130
75
185
Mepivacaine 3% plain
25
90
40
165
Prilocaine 4% plain
20
105
55
190
40
140
60
220
Drug
Medical Emergencies
Drug
Indication
Initial
Pediatric
Dosea
Oxygen
Most medical
emergencies
100% inhalation
100%
inhalation
Epinephrineb
Anaphylaxis
0.30.5 mg im
0.01 mg/kg
im
Asthmatic
bronchospasm
unresponsive to
salbutamol
0.30.5 mg im
0.01 mg/kg
im
Cardiac arrest
1 mg iv
0.01
mg/kgiv
Suspected MI or
unstable angina
160c325 mg orally;
chewing is preferable to
just swallowing (single
dose). Enteric-coated
ASA is not
recommended unless it
is chewed.
N/A
2550 mg iv or im
1 mg/kg iv
or im
Nitroglycerin
Angina pectoris
0.30.6 mg sublingually
N/A
Salbutamol
Asthmatic
bronchospasm
200 g (2 puffs) by
metered dose inhaler
100 g (1
puff) by
metered
dose
inhaler
ASA
a.
The total pediatric dose should not exceed the recommended adult dose.
The dose suggested for the im route is also appropriate for intralingual or sublingual injection.
c.
For 160 mg dose, 2 80 mg children's chewable tablets may be used.
b.