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DENTAL ROSHETTA  Mouth preparation drugs.  Anti - edematous.  Sedative  Muscle relaxants.  Analgesics.  Antibiotics.  Antifungal.  Antiviral.  Corticosteroids.  Vitamins.  Hemostatic drugs  Emergency drugs.  Emergency cases.  Tests  Medical compromised patient  Roshetta Ahmed Hesham 1 Mouth preparation drugs The active ingredient of drugs and it is action:  Benzydamine (NSAIDs): has local analgesics and anti - inflammatory action. (Tantum MW – BBC spray)  Hyaluronic acid: anti - inflammatory – promote healing and decrease duration of ulcers – mediator for periodontal regeneration. (Aftamed – Gengigel – Orovex H)  Chlor hexidine: antimicrobial agent with no resistance – substantivity (last for 12 hours) – gold standard for gingivitis and periodontitis - causes discoloration (if used for long time > 4 weeks) of teeth and tongue. (Hexitol – Orovex – Verolex)  Povidone iodine : it is antiseptic to be used in cases after surgery/ extraction – infected & dry socket – l ess significant in plaque reduction (1% concentration) ( Betadine Mw)  Hydrogen peroxide: antibacterial gram – ve bacteria) & foaming action so it is highly recommended in cases of Pericoronitis – long use > 3 days causes fungal infection & black hairy tongue. Ulcers – localized inflammation: Mouth wash (M.W): o Gengigel (115) / Aftamed (108 ) M.W (hyaluronic acid = promotes healing of ulcers and decreases its duration ) expensive o Tantum verde M.W (NSAIDS) + tetracycline / tetracid 250 mg caps 5ml x4 minor ulcers – pocket – aggressive P. o Tantum verde M.W + betasone 0.5 mg tab. 5ml x4 recurrent multiple ulcers o Epirelefan amp + phenadone syrup + 100 ml saline 5ml x4 major ulcers / immunity ulcers. o Lidocaine viscous 2% oral sol + Benadryl (diphenhydrami ne = antihistaminic & potent L.A ) / phenadone syrup + Maalox plus = ant acid (1:1:1) 5 ml x4 multiple ulcers / viral ulcers o R ifampicin (antibiotic with antiviral action ) = Rifam susp used as M.W & swallow 5ml x3 viral ulcers  It is category C (pregnancy) and cause temporary teeth discoloration. Gel: o Oracure oral gel ( lidocaine gel = not used with children below 6 years as it causes methemoglobinemia). o Aftamed oral gel / Aftamed junior. ( hyaluronic acid = not harmful if swallow ed so can be used with children) o Gengigel oral gel / Gengigel baby (hyaluronic acid) o Kenalog in orabase / Kenacort A orabase (triamcinolone = corticosteroid) o MEBO ointment (it is from natural ingredient) effective for burns and ulcers. o Protopic 0.1 % ointment (tacrolimus) used orally 1x3 / 4 (as in case of lichen ulcer resistant to steroids). Spray: o B.B.C oral spray ( benzocaine = analgesic / benzydamine =NSAIDS / cetalkoniu m = antibacterial ) not u sed with children below 6y o Aftamed spray. Paint: o Salvix - L + tetracycline 250 mg caps 1x3 after meal ( it is carcinogenic) Aggressive periodontitis / severe periodontitis / pocket / diabetic patient (high susceptibility of attachment loss) M.W that contains CHX + Hyaluronic acid: o Orovex - H 80 LE Gingivitis / periodontitis: M.W that contains chlorhexidine: o The previous ( expensive ) o Orovex (CHX + S.F) 45 LE / Parodontax (CHX + S.F ) 3 5 LE o Verolex ( CHX + H2O2) 30 LE o H exitol (CHX) 1x3 for 2 weeks 15 LE Pericoronitis: M.W that contains H2O2 (foaming action + X – anaerobic MOs) o H2O2 30% (one spoon + 20 ml warm water) x 4 for 3 days only then warm salty water as M.W غطا علي ربع كوب ماء دافي اربع مرات يوميا لمدة 3 ايام ثم مضمضة ماية دافية بملح o Verolex M.W. Bleeding gum: o Verolex M. W (H2O2: stop bleeding / CHX: treat inflammation) o Oxymeria M. W  Tannic Acid: stop bleeding esp. in cases of blood disorder  Oxyquinol: anti - septic with mild fungistatic and bacteriostatic drugs. o Gum. C M. W (Vit. C) o Omit.C oral spray (Vit. C) Fungal infection: o Nystatin / mycostatin oral susp used as M.W for 2 min then swallow 5mlx4 x2weeks o Daktarin oral gel / miconaz oral gel 1x4 x 2 weeks. Then after treatment instruct your patient for good oral hygiene & may use Oxymeria MW that has fungistatic activity. Causes of bleeding gum: Blood disorder ( anemia, hemophilia, leukemia..) Bleeding disorder Inflammation : gingivitis .../ hormonal changes. Scurvy: vit.C deficiency. Ahmed Hesham 2 Viral infection: o Rifampicin (Rifam susp) used as M.W & swallow 5ml x3 / Lidocaine viscous 2% oral sol + Benadryl + Maalox plus. o Cream for lip: R/ zovirax cream 1x5x10 days Or R/ penciclovir each 2 hours x 4 days Tooth sensitivity: M.W contains Sodium Fluoride (S.F) o B - fresh M.W 18 LE o EZA – flour M.W. 6.35 LE o DG - wash. 17 LE o Orovex delicate (not contains CHX) 45 LE After surgery / dry/ infected socket : o Betadine M.W. (antiseptic) used the day after surgery. o Antibiotic mouth path : used as irrigation & mouth wash in cases of infected socket:  Tetracycline 250 mg caps O r Dalacin C 300 mg caps + (dissolved in Tantum or saline) o Bivatracin spray ( topical antibiotic spray composed of bacitracin + neomycin) In cases of dehiscence o Betadine M.W. + benzoin Co ( (صبغة جاوي Tooth paste: The active ingredient in tooth paste and it is action:  Chlorohexidine 0.1% (the gold standard antiplaque) : used for gingivitis & periodontitis. DG care tooth paste  Stannous fluoride ( double action : enamel remineralization – broad spectrum antibiotic effect with modulation of the microbial composition of biofilm (decrease gingival inflammation) Parodontax – Sensodyne  Sodium fluoride: enamel remineralization (decrease sensitivity) Sensodyne  Potassium nitrate : decrease tooth sensitivity by interfering with nerve end impulse in dentinal tubule Sensodyne Tooth paste for inflamed gum: + soft brush. R/ DG care tooth paste (CHX gel) R/ Parodontax tooth paste (stannous fluoride) Tooth paste for sensitivi ty: R/ Sensodyne rapid action (stannous fluoride + sodium fluoride) o Leave on your teeth for 5 - 20 min, brush your teeth, split the excess then use S.F - M. W not water يترك علي الاسنان من 5 – 20 دقيقة – ثم تغسل الاسنان يالفرشاة لمدة 3 دقايق – ثم استخدم المضمضة وليس الماء Whitening tooth paste: R/ Theramed whitening power (toothpaste + mouth rinse) R/ close up diamond R/ Crest 3D white. R/ depurdent tooth paste. o Use it for 2 - 3 days per week then complete your routine oral care with sensitivity tooth paste and M. W. Children tooth paste: R/ single / crest / Colgate kids (less fluoride) + soft brush Ahmed Hesham 3 Anti - edematous drugs Indication: It is preventive and curative for edema o To prevent or cure edema in cases of surgery (impaction) or trauma (include also trauma to nerve – trauma to PDL as in cases of TFO or over instrumentation in endo). o In cases of hematoma. Precautions: o Avoid using it to treat edema due to infecti on , as it may lead to spread of infection.as it is proteolytic enzymes that will destroy the fibrous chain that enclose infection. o Avoid using it during eating, as it will digest protein in food instead of inflammatory condition. o Sensitivity: anaphylactic shock is common in cases of injection ( α - chymotrypsin amp) so you must make sensitivity test before each injection. Dose: One or two tabs 3 times daily 1 hour before eating or 2 hours after eating. Sedative Tab  Ambizem - g tab (1 or 2 tab x3) (30 tab = 42. 75 )  Alphintern tab (1 or 2 tab x3) (30 tab = 36 )  Newbezim tab (1 or 2 tab x3) ( 2 0 tab = 24 ) Syrup  Maxillase syrup. (5ml x 3) Gel  Reparil gel N (Aesin = ant edematous & ant inflammatory ) (1x3) o Used in cases of TMJ pain (muscle spasm) – edema.  Hemoclar gel (1x3) o Used in cases of hematoma (anticoagulant action) – edema & pain (anti - inflammatory) Amp  α - chymotrypsin amp (1x2) Sedative Anticonvulsant Antidepressant Diazepam Carbamazepine Amitriptyline Tegr etol 200 mg tab - Tegretol CR 200 mg divitab Long acting anxiolytics (it has extended release so to be used twice) Indication: 1 - Trigeminal neuralgia. Dose : Start with 100 x2 then increase 200 x 4 ( 800 - 1200 mg as maximum) 2 - Stress At bed time and before procedures by 2hours. 3 - TMJ pain + (bruxism) 1/2 tab at bed time for 2 weeks. Precautions: aplastic anemia so CBC each two weeks Gabapentin Gaptin 300 mg caps Neuralgia & neuropathic pain 1x1 (1 st d) then 1x2 then 1x3 Tricyclic antidepressant The safest an d most used: Used in cases of : Stress reduction – muscle spasm - 1 st line during epilepsy attack Use the smallest dose – shortest time (less than 4 weeks) Neuralgia – migraine R/ Valpam 5 mg tab Preoperative sedation : At bed time and / or before procedu res by 2hours. Muscle spasm / anxiety : 5mg x3 (2 – 10 mg x3 /x4) R/ Calmepam 1.5 / 3mg tab (bromazepam) Preoperative sedation : At bed time / before procedure R/ Valpam 2mg/5mg syrup 5ml x3 R/ Neuril 10 mg /2ml amp Emergency drug in cases of seizure Tryp tizol 25 mg tab Amitriptine 50 mg caps 75 up to 150 mg in single or divided dose. Contraindicated with: glaucoma – sleep apnea – severe respiratory depression – children < 6 years Contraindication: Pregnancy (category D) – liver & renal disease. Ahmed Hesham 4 Mus cle relaxants Definition and classification: They are drugs that reduces the muscle tone either by: Periphery (neuro muscular blockers) Centrally Directly (on contractile mechanism)  Competitive blockers: d - tubocurarine, atracurium, gallamine, mivacurium  Depolarizing blockers: succinylcholine, decamethonium Diazepam / Baclofen / Chlorzoxazone Methocar b amol / Cyclobenzaprine Tizanidine Dentrolene Quinine Indication: muscle spasm o TMJ muscular problem. o Myofascial pain dysfunction syndrome. o Bruxism. o Trigem inal neuralgia. Precautions: o Overdose: lead to muscular hypotonia, drowsiness, respiratory depression, coma and convulsions. o Baclofen :  Stimulates gastric acid secretion (avoid it in peptic ulcer)  Abrupt discontinuation can be associated with withdrawal sy ndrome: hallucinations and seizures. o Chlorzoxazone + paracetamol (Myolgin): fatal hepatocellular toxicity. o Use with caution in patients with epilepsy and psychiatric disorders. o Avoid using it in combination with opioids and benzodiazepine. o Avoid using it w ith pregnancy (category C) except cyclobenzaprine (multi - relax) The most commonly muscle relaxants that used in dentistry: o Baclofen: used in cases of neuralgia, multiple sclerosis. Rx: baclofen 10 mg tab 5 mg (1/2 tab) 3 times daily for 3 days 10 mg 3 times daily for 3 days 15 mg 3 times daily for 3 days 20 mg 3 times daily for 3 days (max 8 0 mg / day) o Chlorzoxazone (250) + ibuprofen (200) (Myofen) o Chlorzoxazone + Paracetamol (Myo lgin - parafon ) Rx: myofen tab (1 tab - three times da ily =T .i.d) o Methocar b amol (500) + diclofenac K (50 mg) (Dimra) o Methocar b amol (750) + ibuprofen (400) ( ibuflex ) o Methocar b amol (400) + paracetamol (325) ( methorelax ) Rx: Dimra tab (1 tab - 3 times daily = T.i.d ) Maximum dose: 1500 mg x4 (for 2 /3 days only) – but the half of maximum dose or less is sufficient. o Cyclobenzaprine (very strong: causes drowsiness so to be used at bedtime & if patient improved change to other) (multi - relax) Rx: multi - relax 5 mg tab (1 tab - three times daily = T .i.d) Rx: multi - relax 10 mg tab (1 tab - one time before sleeping) o Tizanidine (Sir dalud - R oysan ) Rx: sirdalud 2 mg tab (1 tab - three times daily = T .i.d) Rx: sirdalud 4 mg tab (1 tab - three times daily = T .i.d) increase gradually each 3 days (Maximum dose 36 mg per day divided each 8 hours) Ahmed Hesham 5 Analgesics Use the Lowest effective dose for the shortest period Injection only for 2 days Strong analgesics in cases of severe pain: 1 - Injection: Ketorolac: one of the strongest NSAIDS ( 30 mg similar to10 morphine) You can mix DEXA amp with it as single shot (DEXA + Ketolac) Ketolac 30 mg amp 1x2 Ketolac 10 mg tab 1x4 Adolor 30 mg amp 1x2 Adolor 10 mg tab 1x 4 FAM 30 mg amp 1x2 FAM 10 mg tab 1X 4 IV : 30 mg as single dose – IM : 60 mg as single dose Maximum: 120 mg daily 20 mg after IV/IM then 10 mg x4 Maximum: 40 mg daily Always begin with pare ntal route (oral route only as continuation of IV/IM if necessary) Duration of therapy should not exceed 5 days Contraindicated with renal impairment 2 - In cases patient refuses injection. o Combination of ibuprofen + paracetamol = strong anti - inflammatory & analgesic action Brufen 400 mg tab + Panadol 500 mg tab 1x 3 Brufen 600 + novaldol 1gm 1x 3 Megafen / cetafen 1x 3 cetafen plus (+ caffei ne) 1x 3 Moderate to severe pain: Strong anti - inflammatory action Brufen Brufen 200 – 400 - 600 tab 1x 3 Brufen 600 sachets 1x 3 Spididol 400 – 600 sachets 1x 3 Dose: 1200 – 1800 mg / day divided (1x3 /1x4) Lowest risk of causing GI bleeding M ax imum do se 3.2 gm/d ay Avoid with hepatic impairment ketoprofen Ketoprek 75 mg caps (rapid action - 6 - 8 hours ) 1x3 / 1x4 (maximum dose 300 mg / day) Strong analgesic action Diclofenac K : rapid onset – short duration Max imum dose 200 mg / day = 4 tab Cataflam 25 - 50 mg tab 1x3 Catafast 50 mg sachets 1x3 Oflam 25 - 50 mg quick tab 1x3 Cataflam 75 mg amp 1x2 Chronic pain: that requires analgesic for long time (TMJ pain) Or peptic ulcer cases Using selective COX II inhibitor to avoid peptic ulcers (weak analgesics – fewer side effects) X efo (lornoxicam) 8 mg 1x2 /1x3 Xefo 8 mg vial IM/IV 1x2 not more 2 days Maximum dose 24 mg / 1 st day (as loading dose) then 16 Mobitil 7.5 / 15 mg tab 1x1 / 1x2 Mobitil 15 mg amp 1x1 Maximum dose 15 mg / day Celecox 200 mg caps 1x1 / 1x2 Maximum dose 400 mg Has cerebrovascular side effects so to be avoided in cases of heart disease. Not used with child ren below 12 years. Bone disease: dry / infected socket – TMJ.  Sulindac : the safest NSAIDs for treating osteoarthritis in older people. (Rudac 200 mg 1x2) o Elevate liver enzymes (not used with hepatic patient)  Indomethacin 50 mg caps 1x 2 / 1x 4 with meal for short period (very strong ) o Has high risk of GI complication (peptic ulcer) & CNS side effect. o Not used < 15 years - Maximum dose 200 mg / day / for maximum 2 weeks. Migraine:  Naproxen 500 mg x2 (used in combination with sumatriptan = trexime t ) Diabetic patient:  Sulindac: prevent cataract...................................Rudac / HiDac 200 mg tab 1x2 (max dose 400 mg day)  Paracetamol. Ahmed Hesham 6 Paracetamol:  Used with (peptic ulcer / TMJ – pregnancy & lactating mother (6months) – baby (1year) – falvism - diabetes – renal imp airment – hepatic patient) Injectmol 1gm/100 ml IV infusion Novaldol 1gm tab strong analgesic Panadol joint In cases of TMJ Hepamol / paralex plus (methionine + paracetamol) For hepatic patient weighing Dose per administration Max. daily dose < 10 k g 7.5 mg / kg 30 mg / kg 10 - 33 kg 15 mg / kg 60 mg / kg (max. 2 gram) 33 - 50 kg 15 mg / kg 60 mg / kg (max. 3 gram) > 50 kg 1 gm 4 gram Minimum interval: 4 hours / max single dose 1 gram / toxic dose > 7 gram in adult – 150 - 200 mg /kg in child Anti dote: N - acetylcysteine (NAC) within 8 hours (loading dose 140 mg/kg then 70 mg.kg every 4 hours for 17 doses) Children:  Injection / suppository 1x2.  Suspension: must be used within 2 weeks. (1x3 - from 3 - 7 days - then 1x2) Healthy child Declophenac K Catafly 2mg /ml susp. Avoided < 3 years ( It is better to be used after 6 years ) Dose: 0.5 – 2 mg / kg /day (5ml x 3) ibuprofen Brufen 100 mg/5ml susp. Dose 20 mg/kg/day ibuprofen +paracetamol Megafen - N 100mg/5ml susp Medical compromise d (falvism – Reyes syndrome) Paracetamol Cetal 250mg/5ml susp. Cetal 120 mg supp In cases of vomiting 1x2 Special consideration: Disease / condition Preferred drug Pregnancy paracetamol 1 st - 2 nd trimester: most NSAIDs are category C 3 rd trimest er: all NSAIDs are category D Children Paracetamol Ibuprofen is the most appropriate NSAIDs for children Renal disease Paracetamol All NSAIDs should be avoided: Ibuprofen, Sulindac, aspirin are the least nephrotoxic risk. Renal stone / colic Diclofen ac is strongest in case of renal colic High CV risk (coronary d isease ) Paracetamol All NSAIDs should be avoided: naproxen is the least CVS risk High G I risk (ulcers – bleeding) Paracetamol Selective COX II inhibitor: Xefo Or use ibuprofen with misopro stol or proton pump inhibitor ( omeprazole ) Asthma and COPD Paracetamol NSAIDS are avoided in case of NSAIDs sensitivity. 8 - 20% experience bronchospasm after NSAIDs Pat ent ductus arteriosus Indomethacin or ibuprofen Primary dysmenorrhea Mefenamic acid (ponstan forte 500 at once then 250 x4 for 3 days ) – Not recommended below 14 years / not more than 1 week Naproxen (naprofen 500 mg tab 1x2 or 5oo mg at once then 250 x4 maximum dose 1250 / day Ahmed Hesham 7 Antibiotics Indication of antibiotics: onl y bacterial infection  Acute infection: o Cellulitis : diffuse swelling. / Involvement of facial space. o Osteomyelitis. / Infected socket. / Severe Pericoronitis. o Acute gingivitis: ANUG / Severe periodontitis (aggressive periodontitis, refractory periodontit is).  After trauma / surgery (impaction, Naocl accident...)  Prophylactic : immunocompromised patient (DM, corticosteroids, radiation ) – heart disease - rheumatoid arthritis. Situations AB is not necessary or contraindicated: o Chronic well localized abscess. / Dry socket. / Mild Pericoronitis. o Chronic gingivitis / mild to moderate periodontitis. / Fungal and viral infection. Penicillin:  Broad spectrum penicillin: is most effective against odontogenic infection esp. acute one o Amoxicillin + clavulanic acid (mostly oral (better bioavailability than ampicillin) – used after meal). o Ampicillin + sulbactam (mostly injection – less absorbed orally ( absorption is impaired by food so 2 hours after meal ) )  Action: act on cell wall (nucleus remain act as spores that may lead to recurrent infection)  Indication: almost all cases esp. acute infection (anti strept)  Duration: at least 5 days / 3 days after S&S disappear (5 - 10 days). 5 days 7 days 10 days pharyngitis - sinusitis – bronchitis. tonsillitis. typhoid – pneumonia – UTI  Dose: 25 mg/ kg: mild case 50 mg/kg: sever case 100 mg / kg: severe and we use injection.  Form: Oral : Tab / caps Suspension (susp) X3 Vial X2 (not divided) (X2 / X3) according to conce ntration. All oral is susp: must be used within 2 weeks IM (3cm) IV (5 - 10 cm)  Drug interaction: o Increase oral anticoagulant action (warfarin) = increase INR ...tendency of bleeding. o B a cteriostatic drugs (tetracycline - erythromycin) decrease act ion of bactericidal (penicillin).  Side effects: o Allergic reaction 10%. o Pseudo membrane colitis. (stop and give metronidazole = flagyl) o Gastrointestinal upset: nausea – vomiting - diarrhea. o Candida infection with long use.  Contraindication: o Allergy to penicil lin: ask him if he had previous allergy – make sensitivity test – asthmatic patient must be tested for each injection - change to erythromycin (1st considered) or clindamycin. o Infectious mononucleosis: amoxicillin causes AB induced skin rash. o Cholestatic j aundice / liver problem (not absolute contraindication but just take your precautions, cephalosporin (not metabolized in livre) is more safe than penicillin in this case.) o Severe renal impairment : need dose adjustment  Crcl 10 - 30 ml/min: 250 - 500 mg/12 hrs ● Crcl < 10 ml/min : 250 - 500 / 24 hrs. Adult Child Dose 25 - 50 mg/kg may reach 100 mg in case of injection Child weight = age x 2 + 8 Tab R/ Hibiotic / Curam / Augmentin 1gm tab 1x2 R/ Hibiotic / Curam / Augmentin 625mg tab 1x 3 Cheap 1 - gram AB: Clavimox (16 tab = 61) Clasynmo (20 Tab =77) – Augram (14 =54) susp Below 6 years R/ Clavimox 312.5 mg 5ml x3 6 - 9 years R/ Clavimox 457 mg 5ml X3 9 - 12 years R/ Hibiotic 600 mg 5ml X 2 / X 3 according to weight (if < 40 kg so 600 x 2) Vial used within 2 hours in room temperature or 4 hours if refrigerated. R/ Augmentin / CURAM 1.2 gm vial 1x2 Ampicillin + sulbactam Dose in severe case : 1.5 to 3 gram x 4 (maximum dose 12 gram – maximum sulbactam dose 4 gram) R/ Unictam / UNASYN 3 gm vial 1x2 (used in severe infection as loading dose in 1 st d ay then decrease dose ) R/ Unictam / UNASYN 1.5 gm vial 1x2 Note: injection is preferred in cases of severe infection or surgery to be used in 1 st 2 /3 days then move to oral AB from the same categ ory. Vial Dose in severe case : 300 mg/kg / day divided to 4 doses Unictam 750 mg vial 1x2 Unictam 375 mg vial 1x2 Ahmed Hesham 8 Cephalosporin: Action, drug interaction, side effects (allergy) the same as penicillin. 1 st generation: anti - gram +ve ( anti - staph ) & so me gram - ve  Indication: many cases esp. chronic / stubborn infection ( anti - staph )  Dose: 25 - 50 mg /kg o Velosef: susp: 125 - 250 mg x2 / Tab: 500 mg – 1gm x2 / Vial: 250 – 500 – 1gm x2 o Ceporex : susp 125 - 250 mg x2 / Tab: 500 – 1gm x2 / Vial: 500 - 1 gm x2 3rd generation: mainly anti - gram – ve o Suprax : 200 mg tab 1x 2 (400 mg / day as single dose or divided every 12 hours) 8 mg /kg / day o Ceftriaxone: 1 - 2 gm IV/IM in single daily dose or every 12 hours. 50 - 75 mg / kg /day or every 12 hours. Used in cases o f surgical prophylaxis o Cefotax : 250 - 500 - 1 gm - 2gm vial IV x 3 50 – 200 mg / kg / day every 8 hours o Fortum (ceftazidime): 250 - 500 – 1 gm vial x2 / x3 30 - 50 mg / kg every 8 or 12 hours May reach to 2 gm x 3 IV / IM in cases of life threatening in fection esp. in medical compromised patient. Used in cases of pulmonary infection / COVOID infection Clindamycin: Indication:  Can be used in all cases instead of penicillin (allergy case as 2nd choice after erythromycin).  Most affective against anaerobic i nfection: o Pericoronitis – abscess – ANUG. o Bony infection ( infected socket / osteoradionecrosis / osteomyelitis): due to its high affinity to bone. Side effects:  Pseudo membrane colitis: diarrhea with abdominal cra mps & pain (stop and use flagyl)  Hypotensi on, jaundice, metallic taste Notes:  No significance drug interaction: It is only AB safe with warfarin.  Avoid using it with nervous colon / ulcerative colitis.  It is bactericidal in large doses.  No dose adjustment needed in renal patient. Dose: 16 - 20 mg /kg = 3 - 4 equal doses per day.  R/ DALACIN - C 300 mg caps 1x3 / 4 x7 R/ DALACIN – C 600 mg amp 1x3 (max dose 1.8 g/d)  R/ CLINDAM – 300 mg caps 1x3 / 4 (cheap) Metronidazole Indication: affective against anaerobic infection.  H - pylori – pseudo membran e colitis. - Pericoronitis – ANUG.  Aerobic & anaerobic infection: sinusitis – aggressive periodontit i s . (not used alone) o Combination with spiramycin: spirazole forte 1x2 before meal. o Combination with (penicillin + clavulanic acid): flagyl + Hibiotic 1 gm tab 1x2 Precautions:  Pregnancy during 1st trimester (teratogenic).  Alcohol consumption up to 3 days / patient treated with disulfiram in the past two weeks. Drug interaction: increase concentration of phenytoin (anti - epilepsy) – alcohol – disulfiram. S ide effects: metallic taste, xerostomia, nausea & vomiting. Dose: 3 5 - 50 mg/kg / day divided in 3 – 4 doses. max dose 4 g/ day.  R/ Flagyl / Amrizole: 250 - 500 mg tab 1x3 for 7 - 10 days.  R/ Flagyl / Amrizole: 125 mg /5ml susp 5ml x3 Macrolides: Action: very strong ( act on ribosomes ) / anti – gram +ve Uses: 1st in cases of penicillin allergy / renal impairment (no dose adjustment) – very safe in pediatrics. Erythromycin: 30 - 50 mg/kg 1x3x5  Dose : erythromycin 200 mg/5ml susp 5ml X 3 X 5 days bef ore meal by one hour. Azithromycin: 10 – 15 mg /kg 1x1x3  Xithrone 200 mg /5ml susp 1x1 before meal for 3 days.  Zithrokan 500 mg 3 caps 1x1x3 before meal by 1 hour.  Neozolid 600 mg 1x1x3 Linezolid Used in cases of resistant infection – wound inf ection – skin infection – bacteremia / septicemia. R/ Averozolid 600 mg tab 1x2 (1 to 2 week) Questionable May be used with cyclospor ine associated gingival enlargement Ahmed Hesham 9 Tetracycline /doxycycline: It is bacteriostatic: avoid using it before bactericidal AB. Contraindicated: pregnancy (category D - teratogenic ) and children < 9y ( discoloration of teeth ) Indication:  Aggressive and refractory periodontitis: due to high concentration in GCV and high substantivit y.  H - pylori infection.  Locally: o In treating ulcers: mixed with Tantum M. w. o Conditioning root: in case of periodontal surge ry. o Avulsed tooth: soaking it in doxycycline for 5 min before implantation (double/ triple revascularization rate) Tetracycline (tetracid) Doxycycline (Vibramycin) Short acting 1x4 Long acting 1x1 (high lipid solubility) Affected by food: chelation with metals e.g. ca, Mg, Fe, Al (teeth bleaching) So used before meal Less chelation (not cause teeth bleaching) fanconi syndrome ( Nephrotoxic metabolite esp. expired tetracycline ) Avoided in hepatic and renal failure Photosensitivity: severe sunburn A bsence No dose adjustment needed Dose: Tetracycline 250 mg caps 1x4 before meal with full glass of water to avoid esophageal ulcer. Doxycycline (Vibramycin) 100 mg caps 1x2 in 1st day then 1x1 for 8 days or 1x2 in severe cases Avoid food, calcium rich produ ct (milk) drugs contains metal (iron) – use sun protective cream Fluoroq uinolones : Indication: in cases of resistant infection – sinusitis – skin & skin fracture infection. Contraindication: pregnancy ( cartilage damage) & children. Side effect: significa nt toxicity, musc le weakness and mental clouding – renal impairment (except Moxifloxacin – metabolized in liver) Drug interaction: potentially fatal drug interaction with cardiovascular drugs. Ciprofloxacin (2 nd G) 250 - 500 mg caps 1x 2 / 1x3 - used in t riple mix antibiotics Tavanic (3 rd G) 500 mg tab 1x1 - used in cases of sinusitis. Moxifloxacin (4 th G) 400 mg tab 1x1 - used in odontogenic infection ( only effective against anaerobic mos.) Quinabiotic (4 th G) 320 mg tab 1x1 Tripl e Antibiotics Mix Composition: Tetracycline 250 mg caps + ciprofloxacin 500 mg + flagyl 500 mg tab + mix with saline / L.A Indication:  Used as intracanal medication in cases of: o Revascularization case (open apex) - Non - vital pulpec tomy - Disinfection of teeth with periapical abscess Preventive / Prophylactic Antibiotics Indication:  Patient with high risk of infective endocarditis: o History of infective endocarditis. o Prosthetic heart valve. o Congenital heart disease. o Heart transplant. o Rheumatic heart disea se.  Medically compromised patient /immunodeficiency: o Cancer – HIV – radio & chemotherapy... o Diabetes mellitus o Hepatic patient.  Patient with artificial joint infection (late stage) Oral 1 hour before procedure Adult Amoxicillin 2 g Clindamycin 600 mg azithr omycin 500 mg Hibiotic 1 g x2 clindam 300 x2 Zithrokan 500 mg tab x1 child Amoxicillin Clindamycin azithromycin 50 mg/kg 20 mg /kg 15 mg /kg Injection 30 min before procedure Adult Unictam 3 gram x1 Dalacin c 600 x1 Ceftriaxone 1gm IV x1 / 5 0 mg/kg for child Ahmed Hesham 10 Antifungal: Topical A ntifungal: Indication: used in treatment of 1ry candidiasis (mild cases)  Thrush – erythematous – hypertrophic candidiasis  Geographic tongue.  Candida associated lesion: o Denture stomatitis. o Median rhomboid glossitis: topical antifungal + corticosteroids. o Angular chelitis: topical antifungal + corticosteroids + vit b complex. Nystatin Dose: R/ N ystatin or mycostatin oral susp 5ml X4 (rinse for 2 min then swallow) Few drops of nystatin can be added to water used for so aking the denture. Child > 1 year: 4 - 6 drops x4 Child < 1 year: 2 drops x4 Precautions Diabetes (as it contains sucrose) Pregnancy and lactating mother (category C) Miconazole Dose R/ Daktarin or M iconazole 2% oral gel (4 times /day/2weeks) Precaut ions Pregnancy & lactating mother (1 st 6 months) – severe liver disease. Topical cream for skin infection: It is combination of (antifungal + antibiotic + corticosteroids)  R/ Kenacomb cream  R/ Polyderm cream Systemic antifungal: Indication: 2nd candidiasi s / mucocutaneous candidiasis (moderate to severe cases) Fluconazole 1 st line of treatment High bioavailability – fewer hepatic enzyme interaction – better GI tolerance – widest therapeutic index. Dose: R/ Diflucan 50 mg tab / 100 mg tab  1 st day: 100 m g X2 (loading dose)  7 - 14 days : 100 mg X1 Children > 6 months R/ Diflucan 25mg/5ml syrup  1 st day: 6mg /kg  7 - 14 days : 3mg / kg Precautions Pregnancy & liver disease (ask for liver function tests before prescribing systemic antifungal) Drug interactions: Decrease W arfarin metabolism (increase anticoagulant = increase bleeding) Increase effect of sulfonylurea = hypoglycemia. Increase effect of phenytoin (anti - epileptic) Cimetidine (TTT for peptic ulcer) decrease effect of fluconazole. Itraconazole Used in refractory cases to fluconazole. (broader spectrum) Dose C hildren > 3 years R/ Itracon 100 mg Caps  100 mg X2 X 7 - 14 days. - should be taken with food (ideally acidic: orange juice) Precautions The same. Avoid getting pregnant whil e taking it & after 2 months from last dose. 4 times / 2 weeks Ahmed Hesham 11 A n tiviral: Indication: used in TTT of viral infection. Herpes simplex:  I t is self - limited disease (7 - 14 days) but using antiviral decrease infectivity, pain, size and duration.  Treat early as possi ble (1st 72 hours of onset) Acyclovir (zovirax): Adult R/ Acyclovir 200 mg tab X5 X (7 - 1 0 days) R/ Zovirax 400 mg tab X3 X (7 - 1 0 days) Child 15 mg/kg ( child< 12 yea rs = 100 mg X 5 X (7 - 10 days) R/ Zovirax 200 mg susp (3ml X5 X (7 - 10 days) RHL Systemic TTT is effective more than topi cal but decrease days to 5 days or use single dose (Famciclovir) Topical Zovirax 5% topical cream 1 x5 x 4 days Penciclovir 1% every 2 - hour x 4 days Docosanol 1x 5 x10 days (its OTC – used in start of lesion – prevent vir us fusion with cells). Precautions Pregnancy (category B) & renal failure Famciclovir: Preferred in cases of immunocompromised patient & older patients:  Higher bioavailability (simpler dose th an acyclovir) & more effective.  More effective in cases of Herpes Zoster & decreasing post - operative herpetic neuralgia. Adult R/ Eaclovir 500 mg tab 1X2 X (7 - 10 days) RHL Single dose: Famciclovir 1500 mg x1 R/ Eaclovir 500 mg 3tab x1 Precautions Pregnancy & renal failure Herpes zoster:  More serious than h erpes simplex so increase dose of antiviral / use more effective drug. o R/ zovirax 400 mg tab 1 x 5 x 7 - 10 days. o R/ Eaclovir 500 mg tab 1 X 3 X 7 - 10 days. Corticosteroids: It is potent anti - inflammatory & immunosuppressive drugs. Ac tion :  Carbohydrate metabolism: o It has anti - insulin effect (increase blood glucose & decrease its uptake = hyperglycemia ) o Resistance to stress: by increasing blood glucose level (adequate supply to brain) o Precautions: diabetes mellitus  Protein metabolism: o Increase protein catabolism ( delay wound healing – wasting of muscle – increase capillary frag ility)  Lipid metabolism: o Increase fatty acid in blood (used for energy production) – long tern corticosteroids ( centripetal obesity)  Electrolyte & water balance : o Na - water retention & K exertion ( increase blood pressure ) – long term usage (Na retention & hypokalemia - expanded extracellular fluid volume ( hypertension )  Blood: o Increase RBCs (help in cases of anemia ) – platelets & 1972 factors ( increase viscosity - coagulation X embolism ) – neutrophils. o Decrease lymphocyte ( reduce immunity, increase fungal infection) – monocytes – basophils & eosinophils. o Potentiate VC effect of adrenaline & angiotensin II.  Effect on bone (osteoporosis) o Decrease absorption of ca and phosphate from intestine (anti - vitamin D) o Decrease osteoblast number and their function. Decrease bone formation o Increase osteoclast activity indirectly (PTH induce osteoclast to increase Ca in blood). bone resorption Ahmed Hesham 12  Effect on skin o Decrease fibrob last proliferation: skin thinning and easy rupture. o Long term topical: skin atrophy – topical steroid addiction (red skin syndrome: itching – redness – swelling after withdrawal)  Immunosuppressive & Anti - inflammatory & anti - allergic : o Impair migration of WBC s & its secretion (cytokines) o Impair arachidonic acid & phosphlipidase metabolism (PG & leukotrienes) o Inhibit lysosomal breakdown (histamine – bradykinin) o Inhibition of T - lymphocyte activation and proliferation & p roduction of plasma cells. o Decrease capilla ry permeability (decrease inflammatory edema) Indication :  Ulcers: major ap h thous ulcers  Oral manifestation of immunity disease (lichen planus – lupus erythematosus – behcets disease - pemphigus ...)  M ucocele: inralesional cortisone to decrease mucocele size.  Allergy / anaphylactic shock.  Nerve injury / bell's palsy / Post herpetic neuralgia.  Before / after surgery (decrease edema & increase recovery) Usage in dentistry: start with topical. Topical Intralesional Systemic Topical corticosteroids:  Us ed 4 times / day (after meal & at bed time – take no thing b y mouth at least one hour after topical steroids).  Decrease duration of treatment as possible to avoid: o Mucosal atrophy. o Candida infection. o Perioral dermatitis. o Increase potential for systemic abso rption.  Tapering gradually: decrease daily dose (2 times instead of 4) then alternate day. Mouth wash Orazone syrup 5ml for 2 min then spit out x4 Tantum verde M.W + betasone 0.5 mg tab 5ml for 2 min then spit out x4 recurrent multiple ulcers Epirelefan amp + phenadone syrup + 100 ml saline 5ml for 2 min then spit out x4 major ulcers / immunity ulcers. G el Kenalog in orabase gel: avoid rubbing it (irritation) & e ating for 30 min. Intralesional : Used in severe / stubborn cases (in combination with topical or systemic or alone).  R/ Epirelefan amp + L.A (to decrease pain during injection) + insulin syringe. o Submucosal insertion of needle in periphery of lesion the n inject slowly during withdrawal. Infiltration: In cases of periapical periodontitis (after endodontic treatment – patient cannot touch tooth)  R/ Dexa amp + L.A (periapical infiltration) Systemic corticosteroids: Low potency & short acting < 12 hours M ode rate (12 - 36 h) High potency & long acting > 48 h Cortisol = Hydrocortisone  Solucortef 100 mg vial Prednisone  Solupred 5 – 20 mg tab  Hostacortin 5mg tab syrup  Xilone 5 mg syrup  Xilone forte 15 mg syrup Prednisolone  Hostacortin H 5 mg tab Triamcinolone  Epi relefan amp  Kenacort A vial. Dexamethasone  Dexamethasone 8 mg amp  Fortecortin 8 mg amp  Epidron 4 mg vial syrup  Phenadone 0.5 mg syrup  Apidone 0.5 mg syrup Betamethasone  Betasone tab 0.5 mg - It is short acting. - It has mineral corticoid action (increase blo od pressure) o more used in children and emergency cases Prednisone is a prodrug and converted to prednisolone (active compound ) in liver. So in hepatic patient give prednisolone (Hostacortin H ) Ahmed Hesham 13 Children; Parental: 1cm/10 kg Oral: 5 mg syrup 2mg/kg/ day 0.5 mg syrup: 0.1 mg/kg/ day (divided on 3) 4 times per day 100 – 500 mg / 6 h / IM – IV For max 3 days then reduce gradually Once or twice 5 - 60 mg/ day For 5 days then tapered over 5 days In ca ses of allergy 4 - 8 mg IM/IV t hen orally (phenadone / apidone = contains antihistaminic) 20 mg hydrocortisone = 5 mg prednisone = 750 mcg dexamethasone Gradual withdrawal: TTT more than 2 weeks or dose more than 40 mg prednisone. Steroid tapering dose: 60 (3d) – 40 (3d) – 20 (3d) - 10 (3d) – 5 (3d) Agent Activity Eq uivalent oral dose (mg) Forms available Anti - inflammatory Topical Salt retaining Hydrocortisone 1 1 1 20 Oral – injectable - topical Prednisone 4 0 0.3 5 Oral Prednisolone 5 4 0.3 5 Oral – injectable Triamcinolone 5 5 up to 100 0 4 Oral – injectabl e – topical Dexamethasone 30 10 0 0.75 Oral – injectable – topical Betamethasone 25 - 40 10 0 0.6 Oral – injectable – topical Fludrocortisone 10 0 250 2 oral Daily cases in dentistry:  Patient complains from severe pain that NSAIDs not sufficient:  Before / after surgery: may be used instead of α - chymotrypsin to avoid sensitivity. o R/ Dexa methasone amp + Ketolac amp (1x1 or 1x2x 2 days )  Allergy after L.A: o R/ Dexamethasone amp or Solucortef 100 mg vial. o R/ Avil amp  Anaphylactic shock: o Adrenaline 1: 1000 0.3 - 0.5 ml IM then olucortef 100 mg vial 1 or 2 - amp IV.  Nerve injury: (depend 1st on vit B - complex) o R/ Neurovit tab 1x1 o R/ Solupred 5 mg tab ( 1 st 5 days: 5mg x4 - 3 days: 5mg x2 - 2 days: 5mg x1 ) Adverse reaction: It is dose (>40 mg) & / or duration depend ent (>2 weeks)  Dose dependent: HTN – D.M – infection.  Dose & duration: Cushing – osteoporosis. Contraindication:  D.M: as it causes hyperglycemia  Pregnancy  Peptic ulcer.  Osteoporosis: So give vit D & Ca  HTN.  Renal failure.  Viral & fungal infection.  T.B  Ang ina & embolism Ahmed Hesham 14 Vitamins: Vitamin C  It is essential for immunity, growth & development, iron absorption and repair of all body tissues.  Antioxidant - Decrease blood pressure – reduce heart disease risk – reduce uric acid level (GOUT)  Important for col lagen synthesis: o Promote wound healing. o Blood vessels integrity o Periodontal ligament o Cartilage, bone and teeth. Deficiency o Decreased immunity, growth and iron absorption. o Impair wound healing. o Bleeding gum. o Mobile teeth. o Bone pain. o Risk of memory disorder Excess Increase oxalate = kidney stone Sleeping problem. Git disorder & diarrhea. Drug interactions Decrease warfarin effect. Decrease oral contraceptive level. Diagnosis CBC: to exclude anemia. Ascorbic acid test. Dose Dose from 1 to 2 tablets - Maximum dose 2000 mg daily R/ C - retard 500 mg caps 1x1 R/ Vitacid – C 1g effervescent 1x1 Vitamin B complex Indication / its deficiency o Nervous injury. o ulceration. o Burning mouth syndrome. o Atrophy of tongue. Dose R/ Milga Advance 1x1 or R/ Neurovit tab 1x1 R/ Neurovit amp 1x 2 x week or (alternate day for two weeks then 1 amp / week) Vitamin E Indication Systemic: it is strong anti - oxidant can be used to decrease side effects of other drugs and to neutralize free radicals produced by drugs - inflammation ...that may lead to cell damage / cancer. Topically : empty the capsule content and applied topically.  Act as antiox idant and membrane stabilizer (protect epithelium lining from breakdown by the direct effect of chemotherapeutic agent and help the broken cells to regenerate)  Ulcers & mucositis due to chemotherapy / chemical burn to mucosa: bleaching burn Dose R/ vit E 1gm caps 1x1 Vitamin A Indication  Anti oxidant.  Promote differentiation, integrity and retard malignancy of epithelium.  Inhibit keratinization. (leukop lakia – lichen ...)  Improve resistance to infection.  Maintains proper bone growth. Dose R/ A viton 50 .000 I.U caps 1x1 or 1x2 Vitamin D & Ca Indication  Periodontal disease.  After surgery (bone removal).  During teething.  Pregnant & lactating mother.  With corticosteroids. S.E of Ca Constipation – bloating gas – stomach upset. Drug interaction Decrease absorption of iron – tetracycline – quinolone - phenytoin Dose Vit D (400 - 1000 unit/day) R/ Davalindi 1000 I.U tab 1x1 R/ vidrop 2800 I.U (8 – 12 drops per day - each drop contains 100 I.U) Ca R/ calcimate 500 mg caps 1x1 after meal Combin ation R/ Decal B12 syrup (Ca + D3 + B12) - 5 cm x1 (prophylactic) - 5cm x3 (therapeutic) R/ osteocar e liquid (ca + D3 + mg + zinc) R/ osteocare tab (ca + D3 + mg + zinc) 1x 1 Ahmed Hesham 15 Iron Indication  In TTT of anemia (sore mouth – ulcers – bleeding gum) o Oral le ss side effects than parental (hypotension – bradycardia..) Dose Adult: 60 (bo y) – 120 mg (pregnant )/ day Primary prevention during pregnancy: 30 mg / day Infants: 2 - 4 mg / kg / day R/ ferrotron caps (iron – zinc – cu – vit c – vit B complex – folic acid) 1x1 before launch R/ Haemojet 100 mg caps 1x1 better absorbed on fasting (may be used after in cases of GIT upset). For 3 months after hemoglobin returns to its normal conc. Avoid tea after eating & after iron treatment , e at f ood rich in vit C (guava, meat , fish and black honey). L actoferrin Indication / action Regulating iron metabolism - in cases of infecti