PHARMACOLOGY REFERENCE
By Michael L. Iczkovitz, D.D.S.
Midwest Oral & Maxillofacial Surgery
Fort Wayne, IN
American Dental Association Sponsored Speaker
1
Diuretics
 Thiazide
Action: Inhibits Na reabsorption in distal renal tubule. Results in increased excretion of
water, sodium, chloride, potassium and hydrogen ions.
Use: Treat mild to moderate hypertension, edema in congestive heart failure and
nephrotic syndrome.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Dry mouth,
paresthesia, headache and orthostatic hypotension. Blood dyscrasias can increase risk
infection, bleeding and poor healing.
Dental Drug Interactions: Tetracycline increases photosensitization. Nonsteroidal antiinflammatory drugs (NSAIDs), especially indomethacin, decreases hypotensive
response.
Hydrochlorothiazide (HydroDiuril)
Metolazone (Zaroxolyn)
Chlorthalidone (Hygroton, Thalitone)
Methyclothiazide (Aquatensin, Enduron)
Indapamide (Lozol)
 Loop
Action: Inhibits Na and Cl reabsorption in loop of Henle and distal renal tubule.
Increases excretion of water, sodium, chloride, magnesium and calcium.
Use: Manage edema of congestive heart failure, hepatic, renal disease and hypertension.
Also pulmonary edema.
Dental considerations: Local anesthesia with vasoconstrictor ok. Watch patients for
orthostatic hypotension. Headache, blood dyscrasias, Stevens-Johnson syndrome.
Dental Drug Interactions: NSAIDs, especially indomethacine, decrease
antihypertensive effect of loop diuretics. Corticosteroids increase electrolyte
imbalance.
Furosemide (Lasix)
Torsemide (Demadex)
Bumetanide (Bumex)
Bumetanide (Bumex)
 Potassium Sparing
Action: Competes with aldosterone receptors at distal renal tubules. Increases sodium
chloride and water excretion, conserves potassium and hydrogen ions.
Use: Treat edema of cirrhosis of liver, hyperaldosteronism, hypokalemia and
hypertension. Treat hirsutism.
Dental considerations: Local anesthesia with vasoconstrictor ok. Gingival bleeding dry
mouth, blood dyscrasias, headache.
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Diuretics
 Potassium Sparing (Continued)
Dental Drug Interactions: Indomethacin and possibly other NSAIDs may cause
nephrotoxicity and decrease hypertensive response.
Spironolactone (Aldactone)
Triamterine (Dyrenium)
 Potassium Sparing* Combinations (Thiazide)**
Action: Competes with aldosterone distal renal tubule and inhibits sodium reabsorption
at distal tubule, loose water, retain potassium.
Use: Treat mild to moderate hypertension, edema of congestive heart failure and
nephrotic syndrome.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Can cause bright
orange tongue, burning of tongue, cracked corners of mouth, blood dyscrasias.
Dental Drug Interactions: Tetracycline increases photosensitization. Nonsteroidal antiinflammatory drugs (NSAIDs), especially indomethacin, decreases hypotensive
response and may cause nephrotoxicity
Triamterene* and Hydrochlorothiazide** (Maxzide, Dyazide)
Adrenergic Inhibitors
 Noncardioselective Beta-Blockers
Action: Blocks beta 1 & 2 stimulation. Results in decreased heart rate, myocardial
contractility, blood pressure and myocardial oxygen demand.
Use: Treat hypertension, angina pectoris, pheochromocytoma, essential tremor, cyanosis
in tetralogy of Fallot, arrhythmias (atrial, A-V nodal reentry, catecholamine induced)
prevention of myocardial infarction, migraine headache, symptoms of hypertrophic
subaortic stenosis. Treat Parkinson’s disease tremor, alcohol withdrawal, aggressive
behavior, antipsychotic induced akathisia, bleeding esophageal varices, anxiety,
schizophrenia, acute panic and gastric bleeding in portal hypertension.
Dental Considerations: Use local anesthesia with vasoconstrictors with caution, may
cause hypertension followed by bradycardia. Dry mouth, paresthesias, blood
dyscrasias, facial swelling and arthralgia.
Dental Drug Interaction: Hypotensive effect decreased by NSAIDs (use ok less than 3
days), penicillin, barbiturates and salicylates. Beta-blockers increase the effect of
acetaminophen and anticoagulants.
Propranolol (Inderal)
Pindolol (Visken) Muscle pain
Nadolol (Corgard) Taste disturbance
Carvedilol (Coreg) Muscle pain, tinnitus, vertigo
Sotalol (Betapace) Life threatening arrhythmia treatment
3
Adrenergic Inhibitors
 Cardioselective Beta-Blockers
Action: Blocks beta 1, reduces cardiac output by slowing heart rate and strength of
contractility and thus reduces myocardial oxygen demand. Also may inhibit renin
release by renal juxtaglomerular apparatus. Reduces spontaneous pacemaker firing
and slows AV nodal conduction.
Use: Treat hypertension, angina pectoris, postmyocardial infarction, acute alcohol
withdrawal, supraventricular and ventricular arrhythmias, and migraine headache
prophylaxis.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Dry mouth, blood
dyscrasias, headache and sore throat.
Dental Drug Interaction: Decreased antihypertensive effect with long term NSAID (can
give safely for three days) and barbiturates. May slow metabolism of lidocaine.
Atenolol (Tenormin)
Metoprolol (Lopressor, Toprol)
Acebutolol (Sectral)
 Alpha 1 Peripheral Blockers
Action: Blocks alpha 1 receptors present in vascular smooth muscle resulting in
peripheral vasodilatation and a decrease in blood pressure. Also relaxes smooth
muscle of bladder neck reducing bladder outlet obstruction.
Use: Treat mild to moderate hypertension, benign prostatic hypertrophy, Raynauds
Syndrome.
Dental Considerations:
Local anesthesia with vasoconstrictor ok. Dry mouth, orthostatic hypotension,
headache, tinnitus and sinusitis.
Dental Drug Interactions:
NSAIDs, Indomethacin decreases effects of alpha 1 peripheral blockers.
Terazosin (Hytrin)
Guanfacine (Tenex)
Doxazosin (Cardura)
Adrenergic Inhibitors +
 Alpha 1 Peripheral Blocker* and Thiazide Diuretic**
Hydroflumethiazide** and Reserpine* (Salutensin)
Action: **Produces diuresis, *depletes sympathetic amines (norepinephrine and
dopamine) to reduce blood pressure.
Use: Management of hypertension
Dental Considerations: Local anesthesia with vasoconstrictor ok. Blood dyscrasias,
photosensitivity, paresthesia, dry mouth and headache.
Dental Drug Interactions: NSAID decrease hypotensive response, Tetracycline
increases photosensitivity.
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Adrenergic Inhibitors

Noncardioselective Beta-Blocker and Alpha-Blocker
Labetalol (Normodyne, Trandate)
Action: Blocks beta-1, beta-2 and alpha-receptors, reduces rennin levels.
Use: Mild to severe hypertension
Dental Considerations: Noncardioselective beta-blockers mixed with vasoconstrictor in
local anesthesia, epinephrine, may cause initial hypertension followed by bradycardia.
Dry mouth, altered taste, lichenoid reaction, headache, paresthesia, orthostatic
hypotension, blood dyscrasias, tinnitus, sore throat, fever, arthralgia.
Dental Drug Interactions: Decreases metabolism of lidocaine. NSAIDs decrease
medications hypotensive effects, less than three-day use ok. Barbiturates decrease
hypotensive effects also. Hydrocarbon inhalation general anesthetics increase
hypotension and cardiac depression.
 Central Acting Alpha 2 Agonists
Action: Stimulates alpha 2 receptors in brain stem. Reduces sympathetic outflow,
decreases blood pressure, pulse rate and cardiac output. Peripheral vasodilatation.
Use: Treat mild to moderate hypertension, heroin withdrawal and smoking cessation,
migraine prophylaxis, glaucoma, paralytic ileus and diabetic diarrhea.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Dry mouth,
orthostatic hypotension, headache, blood dyscrasias.
Dental Drug Interactions: Increased sedation with alcohol and all CNS depressants.
Clonidine (Catapres)
Adrenergic Inhibitor +
 *Beta Blocker and **Diuretic
Action: Beta 1 blocker reduces cardiac output. Thiazide diuretic increases renal
excretion of water, sodium, chloride, potassium and hydrogen ions.
Use: Treatment of hypertension.
Dental Considerations: Local anesthesia with vasoconstrictor ok with cardioselective,
not with noncardioselective. Headache, arthralgia, myalgia, blood dyscrasias, dry
mouth, photosensitivity and orthostatic hypotension
Dental Drug Interactions: Don’t use NSAIDs longer 3 days, reduces hypotensive effect,
Tetracycline increases photosensitivity.
*Bisoprolol and **Hydrochlorothiazide (Ziac) *Cardioselective,
sore throat
*Propranolol and **Hydrochlorothiazide (Inderide)
*Noncardioselective, paresthesia.
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Vasodilators
 Direct Acting
Action: Direct vasodilatation of arterioles (with little effect on veins), decreases
systemic resistance. Decreases blood pressure, reflex increases cardiac function.
Use: Treat moderate to severe hypertension, congestive heart failure, hypertension
secondary to eclampsia and primary pulmonary hypertension.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Headache, flushing of
face, blood dyscrasias.
Dental Drug Interactions: NSAIDs decrease hypotensive effect of this medication.
Hydralazine (Apresoline)
 Peripheral Vasodilator
Action: Alpha-adrenergic antagonist, beta-adrenergic stimulators. Acts directly on
vascular smooth muscle causes cardiac stimulation and uterine relaxation.
Use: Symptoms of cerebrovascular insufficiency, peripheral vascular disease such as
arteriosclerosis obliterans, thromboangitis obliterans and Raynaud’s disease.
Dental Considerations: Local anesthesia with vasoconstrictor ok.
Dental Drug Interactions: Increases effects of alcohol.
Isoxsuprine (Vasodilan)
 Angiotensin Converting Enzyme (ACE) Inhibitors
Action: Inhibiting this enzyme prevents angiotensin I converting to angiotensin II.
ANGIOTENSIN II is potent vasoconstrictor, results in increased renin release,
reduction in aldosterone secretion and lower blood pressure.
Use: Treat hypertension and congestive heart failure.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Dry mouth, headache,
orthostatic hypotension, angioedema, paresthesias and blood dyscrasias.
Dental Drug Interactions: NSAIDs decrease hypotensive effect of ACE inhibitors.
Lisinopril (Prinival, Zestril)
Enalapril (Vasotec)
Benazepril (Lotensin)
Quinapril (Accupril)
Fosinopril (Monopril)
Captopril (Capoten)
Ramipril (Altace)
Moexipril (Univasc)
Trandolapril (Mavik)
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Vasodilators +
 *ACE Inhibitor and **Thiazide Diuretic
Action: Thiazides cause diuresis due to inhibition Na reabsorption in distal tubule. ACE
less formation of vasoconstrictor angiotensin II, less aldosterone secretion.
Use: Treatment of hypertension.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Dry mouth,
angioedema, paresthesias, headache, orthostatic hypotension and blood dyscrasias.
Dental Drug Interactions: NSAIDs decrease effect of medication.
*Lisinopril and **Hydrochlorothiazide (Prinizide, Zestoretic)
*Moexipril and **Hydrochlorothiazide (Uniretic)
*Captopril and **Hydrochlorothiazide (Capozide)
Calcium Channel Blockers
Action: Inhibits calcium ion influx across cell membrane during cardiac depolarization.
Relaxes vascular smooth muscle thus dilating coronary and peripheral arteries. Also
decreases SA/AV node conduction.
Use: Treat hypertension and angina pectoris.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Gingival hyperplasia,
dry mouth, altered taste, headache, myalgia, sinusitis, paresthesia, joint stiffness.
Dental Drug Interactions: Effect of calcium channel blockers is decreased by
indomethacin, other NSAIDs, barbiturates.
Amlodipine (Norvasc)
Nifedipine (Adalat, Procardia)
Diltiazem (Cardizem, Tiazac, Dilacor, Cartia)
Verapamil (Calan, Isoptin, Verelan)
Isradipine (DynaCirc)
Felodipine (Plendil)
Nisoldipine (Sular)
Angiotensin II Receptor Blockers (ARBs)
Action: Inhibits angiotensin - renin system like ACE inhibitors. Blocks vasoconstrictor
and aldosterone releasing effects of angiotensin II. Thus increases urinary flow,
excretion chloride, magnesium, uric acid, calcium and phosphate.
Use: Treat hypertension.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Myalgia, orthostatic
hypotension, migraine headache, taste alteration, paresthesia, tinnitus.
Dental Drug Interactions: Ketoconazole and sedatives increases hypotensive effects of
ARBs.
Losartan (Cozaar)
Valsartan (Diovan)
Irbesartan (Avapro)
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Angiotensin II Receptor Blockers (ARBs) (continued)
Candesartan (Atacand)
Eprosartan (Teveten)
Telmisartan (Micardis)
Angiotensin Receptor Blockers +
 Combination with Thiazide Diuretic
Action: ARBs inhibits angiotensin - renin system. Blocks vasoconstrictor and
aldosterone releasing effects of angiotensin II. Diuretic inhibits Na reabsorption in
distal renal tubule. The net effect is to increase urinary flow; excretion of water,
chloride, magnesium, uric acid, calcium, phosphate, sodium, potassium and hydrogen
ions.
Use: Treatment of hypertension
Dental Considerations: Local anesthesia with vasoconstrictor ok. Dry mouth, orthostatic
hypotension, migraine headache, facial edema, taste alteration, paresthesia, tinnitus,
myalgia, blood dyscrasias.
Dental Drug Interactions: Tetracycline increases photosensitization. Nonsteroidal antiinflammatory drugs (NSAIDs), especially indomethacin, decrease hypotensive
response. Ketoconazole and sedatives increase hypotensive effects.
Losartan and Hydrochlorothiazide (Hyzaar)
Telmisartan and Hydrochlorothiazide (Micardis HCT)
Irbesartan and Hydrochlorothiazide (Avalide)
Vasodilators +
 ACE Inhibitors* Combined with Calcium Channel Blocker**
Action: ACE inhibits angiotensin - renin system, decreases aldosterone release and
increases diuresis. Calcium Channel blockers relax vascular smooth muscle and
myocardium.
Use: Treat hypertension.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Headache.
Dental Considerations:
Ca Channel: Gingival hyperplasia.
ACE: Orthostatic hypotension, angioedema, dry mouth and paresthesia.
Dental Drug Interactions: Hypotensive effect decreased by NSAIDs, barbiturates.
Amlodipine** and Benazepril* (Lotrel)
Enalapril* and Felodipine** (Lexxel)
Trandolapril* and Verapamil** (Tarka)
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Electrolyte Supplement
 Potassium Salt
Action: The major intracellular fluid cation, essential for conduction of nerve impulses
in heart, brain and skeletal muscle; necessary for contraction of cardiac, skeletal and
smooth muscle.
Action: Also maintains normal renal function, acid-base balance, carbohydrate
metabolism and gastric secretion.
Use: Prevention and treatment of hypokalemia including that secondary to drugs.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Paresthesia and throat
pain.
Dental Drug Interactions: Corticosteroids decrease potassium requirements; NSAIDs
increase GI side effects of potassium salts.
Potassium Chloride (Klotrix, K-Dur, Klor-Con)
Nitrates
Action: Reduces cardiac oxygen demand by decreasing systemic vascular resistance and
left ventricular pressure. Dilates coronary arteries and improves collateral flow to
ischemic regions.
Use: Treat angina pectoris, congestive heart failure (especially if due to MI), pulmonary
hypertension and hypertensive emergencies perioperatively.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Dry mouth, oral
burning sensation, postural hypotension, and headache.
Dental Drug Interactions: Increased hypotensive effects with alcohol, opiods, aspirin in
1 gram single doses, benzodiazepines and other drugs used in conscious sedation.
Nitroglycerin (Nitrostat, Nitro-Dur, Transderm-Nitro)
Isosorbide Mononitrate (Imdur)
Isosorbide Dinitrate (Isordil)
Cardiac Glycoside
Action: Increases myocardial contractility by inhibiting sodium/potassium ATPase
pump, which makes more calcium available for contractile proteins. Also suppresses
AV node conduction.
Use: Congestive Heart Failure (CHF), atrial fibrillation, atrial flutter, paroxysmal atrial
tachycardia and cardiogenic shock.
Dental Considerations:
Use local anesthesia with vasoconstrictor with caution, risk cardiac arrhythmias. Have
increased gag reflex (difficulty taking impressions), headache, neuralgia and
photophobia.
Dental Drug Interaction: Medication effect decreased by Antacids increased by
barbituarates and erythromycin. Use with corticosteroids causes hypokalemia.
Digoxin (Lanoxin, Digitek)
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Antiarrhythmic Agents
Propafenone (Rythmol)
Action: Local anesthetic properties, slows conduction velocity, reduces cardiac muscle
responsiveness, inhibits automaticity, increases refractory period and has beta blockade
activity.
Use: Treat life threatening ventricular arrhythmias, supraventricular arrhythmias (WolfParkinson-White syndrome).
Dental Considerations: Local anesthesia with vasoconstrictor ok. Dry mouth, altered
taste, stomatitis, tinnitus, headache, paresthesias and blood dyscrasias.
Dental Drug Interactions: Increases levels of warfarin and local anesthetics.
Flecainide (Tambocor)
Action: Local anesthetic properties, slows conduction velocity, increases refractory
period, moderate negative ionotropic effects.
Use: Life threatening ventricular arrhythmias, sustained supraventricular tachycardia.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Dry mouth, altered
taste, headache, blood dyscrasias, tinnitus, paresthesia, photophobia, swelling lips,
tongue, mouth, arthralgia, myalgia.
Dental Drug Interactions: None.
Disopyramide (Norpace)
Action: Decreases myocardial excitability and conduction velocity. Reduces refractory
disparity between normal and infarcted myocardium.
Possesses anticholinergic, peripheral vasoconstrictive and negative inotropic effects.
Use: Treat premature ventricular complexes, ventricular tachycardia. Conversion of
atrial fibrillation, atrial flutter and paroxysmal atrial tachycardia to normal sinus
rhythm and prevention of reoccurrence of these arrhythmias after conversation by other
methods.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Dry mouth,
paresthesia, headache and blood dyscrasias.
Dental Drug Interactions: Toxicity of medication increased by Erythromycin.
Increased side effects with anticholinergics, alcohol. Decreased effects with
barbiturates and corticosteroids.
Amiodarone (Cordarone, Pacerone)
Action: Inhibits adrenergic stimulation, prolongs the action potential and refractory
period in myocardial tissue, decreases A-V conduction and sinus node function.
Use: Management of life threatening ventricular arrhythmias or supraventricular
arrhythmias unresponsive to conventional therapy with less toxic agents.
Dental Considerations: Local anesthesia with vasoconstrictor can cause bradycardia and
hypotension. Bitter taste, dry mouth, headache, paresthesia, alveolitis, abnormal
salivation, blood dyscrasias and photophobia.
Dental Drug Interactions: Increases photosensitivity of tetracyclines. Bradycardia and
hypotension with inhalation anesthetics, lidocaine and anticholinergics.
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Oral Anticoagulant
Warfarin (Coumadin)
Action: Interferes with hepatic synthesis of vitamin K dependent coagulation factors (II,
VII, IX and X).
Use: Prophylaxis and treatment of venous thrombosis, pulmonary embolism and
thromboembolic disorders, atrial fibrillation with risk of embolism and to prophylaxis
against systemic embolism after myocardial infarction.
Dental Considerations: Gingival bleeding may indicate overdose, mouth ulcers, salivary
gland pain and or swelling, fever, blood dyscrasias.
Dental Considerations: Delay surgical procedures until INR is below 2.5 either by
having patient lower dose of medication taken or temporarily not take medication.
Dose adjustment should be with physician consultation.
Dental Drug Interactions: Cephalosporins, erythromycin, tetracycline, parental
penicillin, NSAIDs, indomethacin, salicylates, acetaminophen, propoxyphene,
diflunisal, metronidazole, ketoconazole, corticosteroids, chloral hydrate increase
anticoagulant activity.
Dental Drug Interactions: Barbiturates and oral antibiotics (effects on GI bacteria
producing Vitamin K), alcohol decreases anticoagulant effects of this medication.
Antiplatelet Agent
 Dipyridamole (Persantine)
 Cilostazol (Pletal)
Action: Inhibits ability of platelets to aggregate through effects on adenosine, cAMP and
thromoxane A2. May also cause peripheral and coronary vasodilatation.
Use: Prevention of transient ischemic attacks (TIAs), MI, thromboembolism, with
warfarin for prosthetic heart valves, with aspirin to prevent occlusion of coronary
artery bypass grafts (CABGs).
Dental Considerations: Local anesthesia with vasoconstrictor ok. Gingival bleeding,
headache, migraine, postural hypotension.
Dental Drug Interactions: Additive antiplatelet effects with aspirin and other NSAIDs.
 Ticlopidine (Ticlid)
Action: Inhibits first and second phases of ADP induced effects of platelet
aggregation.
Use: Reduce risk of stroke in high-risk patients. Prophylaxis for CABG,
diabetic microangiopathy, ischemic heart disease, deep vein thrombosis,
post renal transplant.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Blood
dyscrasias and tinnitus.
Dental Drug Interactions: Increased bleeding with anticoagulants, aspirin
and NSAIDs.
11
Antiplatelet Agent
 Clopidogrel (Plavix)
Action: Indirectly blocks binding of fibrinogen to the ADP receptor
Use: Reduction of atherosclerotic events (myocardial infarction, stroke, vascular deaths)
in patients with atherosclerosis documented by recent MI, stroke or established
peripheral arterial disease.
Dental Considerations: Local anesthesia with vasoconstrictor ok.
Dental Drug Interactions: None
Blood Viscosity Reducing Agent
 Pentoxifylline (Trental)
Action: Decreases blood viscosity.
Use: Intermittent claudication due to chronic occlusive arterial disease of limbs.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Dry mouth, altered
taste, headache, blood dyscrasias.
Dental Drug Interactions: May increase coumadin activity.
Cholesterol Lowering Agents
 HMG-CoA Reductase Inhibitors:
Action: Inhibits enzyme involved in cholesterol biosynthesis, thus lowers cholesterol
production.
Use: Treat primary hypercholesterolemia.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Headache, arthralgia,
facial paresis, dryness of mucous membrane and myalgia.
Dental Drug Interactions: Increased effect of Erythromycin and Warfarin. Don’t use
with Erythromycin and azole antifungals, can result in rhabdomyolysis.
Simvastatin (Zocor)
Pravastatin (Pravachol)
Lovastatin (Mevacor)
Fluvastatin (Lescol)
Atorvastatin (Lipitor)
Cerivastatin (Baycol) removed from market August 2001, fatal
rhabdomyolysis at high doses and when mixed with Lopid.
12
Cholesterol Lowering Agents
 Miscellaneous
Gemfibrozil (Lopid)
Action: Mechanism of action unknown.
Use: Treat hypertriglyceridemia, coronary heart disease with increased LDL cholesterol,
triglycerides and low HDL cholesterol.
Dental Considerations: Local anesthesia with vasoconstrictor ok, paresthesia,
hypesthesia, headache and blood dyscrasias.
Dental Drug Interactions: May potentiate effects of warfarin.
 Miscellaneous
Niacin (Slo-Niacin, Nicobid)
Action: Vitamin B 3 inhibits synthesis of low-density lipids (LDL). Needed for
conversion of fats, proteins and carbohydrates. Acts directly on vascular smooth
muscle to cause vasodilatation.
Use: Treat hypercholesterolemia, niacin deficiency = pellagra (may arise from chronic
alcoholism, GI disturbances, pregnancy, hyperthyroidism, and infections).
Dental Considerations: Local anesthesia with vasoconstrictor ok. Dry mouth, headache
and paresthesia.
Dental Drug Interactions: Drug effect decreased by Aspirin.
 Miscellaneous
Cholestyramine Resin (Questran)
Action: Absorbs, combines with bile acids to form insoluble complex that is excreted
through feces. Loss of bile acids lowers cholesterol.
Use: Treat hypercholesterolemia, pruritis with elevated bile acids, diarrhea secondary to
excess fecal bile acids, binding toxicological agents, pseudomembraneous colitis.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Tongue irritation,
headache, tinnitus, muscle and joint pain.
Dental Drug Interactions: Decreased absorption of tetracyclines, cephalexin,
barbiturates, corticosteroids, clindamycin, penicillins, warfarin and NSAIDs.
 Miscellaneous
Coesevelam (WelChol)
Action: Binds with bile acids in the intestine, increases fecal loss and lowers LDL.
Use: Treat elevated levels of LDL.
Dental Considerations: Local anesthesia with vasoconstrictor ok. TMJ-myalgia,
pharyngitis.
Dental Drug Interactions: None
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Cholesterol Lowering Agents
 Miscellaneous
Fenofibrate (Lipidil, Tricor)
Action: Enhances lipase synthesis and increases LDL catabolism. Decreases LDL and
total plasma triglycerides, may increase HDL.
Use: Treat elevated cholesterol; reduce LDL, total cholesterol, triglycerides, and
apolipoprotein.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Pain, headache,
myalgia, photosensitivity, and joint pain.
Dental Drug Interactions: None
Beta 2 Adrenergic Agonist
Action: Beta 2 stimulation relaxes bronchial smooth muscle causing bronchodilation
with little effect on heart rate.
Use: Treat reversible airway obstruction due to asthma or COPD (chronic obstructive
pulmonary disease; bronchitis, emphysema). Prevention of exercise induced asthma
and bronchospasm.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Facial flushing,
headache, dry mouth, unusual taste, discoloration of teeth, muscle cramps.
Dental Drug Interactions: Increased toxicity (arrhythmias) with inhalation anesthetics.
Albuterol (Proventil, Ventalin, Volmax)
Salmeterol Xinafoate (Serevent)
Pirbuterol (Maxair)
Albuterol (liquid form)
Metaproferenol (Alupent)
Formoterol (Foradil)
Theophylline Derivative
Action: Blocks phosphodisterase increases cAMP. Results in adrenal medulla releasing
epinephrine and causing bronchodilation. Also causes diuresis, CNS and cardiac
stimulation.
Use: Treat reversible airway obstruction due to asthma, chronic bronchitis, and
emphysema. Also neonatal apnea/bradycardia.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Bitter taste, dry
mouth and headache.
Dental Drug Interactions: Medication levels increased by corticosteroids, erythromycin
and ephedrine. Decreased by barbiturates and ketoconazole. Decreases sedative
effects of benzodiazipines. Increased risk of cardiac arrhythmias with inhalation
anesthetics.
Don’t give Erythromycin with this medication.
Get nausea, vomiting and CNS restlessness.
Theophylline/Aminophylline (Theo-Dur)
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Corticosteroids
 Oral
Action: Anti-inflammatory by suppressing migration of PMN leukocytes and decreasing
capillary permeability. Immunosuppressant by reducing activity and volume of
immune system.
Use: Treat adrenocortical insufficiency, hypercalcemia, rheumatoid and collagen
disorders, dermatologic, ocular, respiratory, GI and neoplastic diseases, organ
transplantation.
Use: Treat variety of diseases of allergic, inflammatory or autoimmune origin.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Use with caution if
hypertension, CHF, thromboemboli, GI disease, hypothyroid, cirrhosis. May retard
bone growth. If systemic use watch for adrenal insufficiency and crisis. Don’t use if
serious infection or GI bleeding.
Dental Considerations: Dry mouth, candidiasis, poor wound healing, headache and
blood dyscrasias. Don’t give if pregnant. Lactation ok.
Medical Considerations: >10%; insomnia, nervousness, increased appetite,
indigestion.
Medical Considerations: Other adverse reactions; depression, flushing, sweating,
headache, mood changes, hypertension, circulatory collapse, thrombophlebitis,
embolism and tachycardia, diarrhea, nausea, abdominal distention, GI hemorrhage,
pancreatitis, increased intraocular pressure, blurred vision, acne, ecchymosis,
petechiae, fractures, osteoporosis, weakness.
Drug Interactions: Decreased effect with barbiturates, rifampin, rifabutin and
phenytoins. Increased side effects with alcohol, salicylates, NSAIDs. Don’t use
aspirin products with this medication.
Drug Interactions: Decreases effect of salicylates, vaccines and toxoids. Increases
action of ketoconazole and macrolide antibiotics.
Prednisone (Deltasone)
Corticosteroids
 Inhalant
Action: Anti-inflammatory
Use: Treat asthma. Spray form used to treat seasonal and perennial allergic rhinitis.
Topical forms for eczema and inflammatory skin disorders.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Dry mouth, perioral
dermatitis, arthalgia, headache and candidiasis.
Dental Drug Interactions: None
Fluticasone (Flonase, Flovent)
Triamcinolone (Azmacort)
Flunisolides (AeroBid, Nasalide)
Beclomethasone (Vanceril, Vancenase, Beconase)
Budesonide (Rhinocort, Pulmacort)
15
Corticosteroids +
Fluticasone* and Salmeterol** (Advair)
Action, Use, Dental Considerations and Dental Drug Interactions: Same as individual
components, an anti-inflammatory* and beta 2 adrenergic agonist. **
 Topical
Action: Anti-inflammatory
Use: Relief of inflammatory and pruritic manifestations of dermatoses.
Dental Consideration and Drug Interactions: None
Mometasone (Elocon, Nasonex)
Hydrocortisone Cream (Westcort)
Mast Cell Stabilizer
 Inhalant
Action: Prevents histamine release.
Use: Prophylactic management of asthma, attenuates bronchospasm
Dental Considerations: Local anesthesia with vasoconstrictor ok. Dry mouth,
unpleasant taste, swollen parotid gland, angioedema and headache.
Dental Drug Interactions: None
Cromolyn (Intal, Nasalcrom)
Anticholinergic
 Inhalant
Action: Blocks acetylcholine at parasympathetic receptor sites of bronchial smooth
muscle, causes bronchodilation.
Use: Treat COPD, bronchitis and emphysema. For maintenance treatment only.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Dry mouth,
stomatitis, metallic taste, and headache.
Dental Drug Interactions: Increases effects of anticholinergics.
Ipratropium (Atrovent)
Anticholinergic +
 Inhalant
Ipratropium* and Albuteral** (Combivent)
Action, Use, Dental Considerations and Dental Drug Interactions: Same as individual
components, an anticholinergic* and beta 2 adrenergic agonist. **
16
Leukotriene Receptor Antagonist
 Oral
Action: By blocking leukotriene and slow reaction substance prevents airway edema,
smooth muscle constriction and altered cellular activity of inflammation associated
with signs and symptoms of asthma.
Use: Prophylaxis and chronic treatment of asthma in adults and children >11 years of
age.
Dental Considerations: Local anesthesia with vasoconstriction ok. Headache, fever,
myalgia.
Dental Drug Interactions: Erythromycin decreases effects, aspirin increases effects,
increases effects of warfarin.
Zafirlukast (Accolate)
Montelukast (Singulair)
Anti-Depressants
 Tricyclic Antidepressants (TCAs)
Action: Increases CNS serotonin and norepinephrine concentration. Also has
anticholonergic and sedating effects.
Use: Treat major depression, enuresis, analgesic for chronic and neuropathic pain,
prophylaxis for migraine headaches.
Dental Considerations: Use of local anesthesia with vasoconstrictor can cause
hypertension. Dry mouth, unpleasant taste, salivary gland pain, paresthesias, blood
dyscrasias, headache, postural hypotension, tinnitus and gingival reactions.
Dental Drug Interactions: Medication effect decreased by Vit.C and barbiturates,
increased by meperidine and antihistamines.
Dental Drug Interactions: Increases anticholinergic effects of antihistamines. Increased
CNS depression with alcohol, barbiturates and benzodiazepines.
Amitriptyline (Elavil)
Imipramine (Tofranil)
Doxepin (Adapin, Sinequan)
Desipramine (Norpramin, Pertofrane)
Clomipramine (Anafranil)
Protriptyline (Vivactil)
Nortriptyline (Aventyl, Pamelor)
17
Anti-Depressants
 Tetracyclic Antidepressant
Action: In CNS blocks adrenergic alpha 2 inhibitory receptors, serotonin receptors and
histamine receptors.
Use: Treat depression.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Significant dry
mouth, thirst, glossitis, gingival hemorrhage, stomatitis, tongue discoloration and
edema. Aphthous stomatitis, candidiasis, salivary gland enlargement, orthostatic
hypotension, blood dyscrasias, sinusitis, arthralgia, myalgia.
Dental Drug Interactions: Barbiturates decrease medication effect, impairment of
cognitive and motor performance with opiod analgesics and benzodiazipines. Additive
effect with other anticholinergics.
Mirtazapine (Remeron)
 TCA* and Phenothiazine**
Action: TCA increases CNS serotonin and norepinephrine concentration.
Phenothiazine causes dopaminergic neurotransmitter blockade in the cerebral cortex,
hypothalamus and limbic system and depresses hormone release. Also strong
peripheral Alpha-adrenergic blockade, anticholinergic.
Use: Treat moderate to severe anxiety and depression.
Dental Considerations: Use of local anesthesia with vasoconstrictor can cause
hypertension. Dry mouth, unpleasant taste, salivary gland pain, paresthesias,
orthostatic hypotension, tinnitus, gingival reactions, headache, blood dyscrasias and
laryngospasms.
Dental Drug Interactions: Medication effect decreased by Vit. C and barbiturates,
increased by meperidine and antihistamines. Increased sedation CNS depressants,
alcohol, barbiturates. Increased anticholinergic effects with anticholinergics. Additive
photosensitivity with tetracyclines.
Amitriptyline* and Perphenazine** (Etrafon, Triavil)
 Selective Serotonin Reuptake Inhibitors
Action: In CNS, no effect on reuptake of norepinephrine or dopamine. Just inhibits
reuptake of neurotransmitter serotonin. Doesn’t bind to alpha-adrenergic, histamine or
cholinergic receptors; thus less hypotensive, sedative or anticholinergic effects, which
are common with TCAs.
Use: Treat major depression, bulimia, obsessive-compulsive disorder and premenstrual
tension.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Dry mouth, taste
changes, dysphagia, aphthous stomatitis, headache, sinusitis, tinnitus, pharyngitis,
photophobia, myalgia and fever.
Dental Drug Interactions: Increases toxicity of diazepam. Increases side effects of
protein bound drugs, i.e. aspirin. Increased CNS depression with alcohol, CNS
depressants.
Fluoxetine (Prozac)
18
Anti-Depressants
 Selective Serotonin Reuptake Inhibitors (continued)
Sertraline (Zoloft) Panic disorders, myalgia
Paroxetine (Paxil) Anxiety,, glossitis, salivary gland enlargement.
Fluvoxamine (Luvox) Panic disorders, increased salivation (more often dry
mouth), postural hypotension
Citalopram (Celexa)
 Antimanic Agent
Action: Blocks CNS reuptake of serotonin and norepinephrine. Also alters sodium and
potassium ion transport across nerve and muscle cells.
Use: Treat acute manic episodes, bipolar manic depressive psychosis, depression and
vascular headaches.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Dry mouth, thirst,
headache, tinnitus and blood dyscrasias.
Dental Drug Interactions: Do not use Aspirin, Indomethacin or other NASIDs with,
causes lithium toxicity. Xanthines (caffeine) with decrease effect of lithium.
Lithium (Eskalith)
 Miscellaneous Antidepressants
Trazodone (Desyrel)
Action: Inhibits CNS reuptake of serotonin and norepinephrine.
Use: Depression, chronic pain, painful diabetic neuropathy and burning mouth
syndrome.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Dry mouth, bad taste,
stomatitis, headache and orthostatic hypotension.
Dental Drug Interactions: Decreases effect of anticoagulants. Increases effect of CNS
depressants.
Nefazodone (Serzone)
Action: Inhibits CNS reuptake of serotonin and norepinephrine.
Use: Major depressive orders.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Dry mouth, taste
alteration, candidiasis, stomatitis, headache, orthostatic hypotension, pharyngitis.
Dental Drug Interactions: Significant adverse reaction with alcohol.
Bupropion (Wellbutrin, Zyban)
Action: Weak CNS reuptake inhibitor of serotonin, norepinephrine and dopamine.
Use: Treat depression and tobacco addiction.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Significant dry
mouth, headache and fever.
Dental Drug Interactions: Increased seizure activity with benzodiazepines and alcohol.
19
Anti-Depressants
 Miscellaneous Antidepressants
Venlafaxine (Effexor)
Action: Inhibits both norepinephrine and serotonin CNS reuptake. Weak inhibitor of
dopamine reuptake.
Use: Depression.
Dental Considerations: Local anesthesia with vasoconstrictor ok.
Dental Considerations: Significant dry mouth, glossitis, cheilitis, gingivitis, candidiasis,
postural hypotension, blood dyscrasisas and headache.
Anti-Anxiety Agent
 Benzodiazepines
Action: Decreases all levels of the CNS, including the limbic and reticular formation.
Does this by facilitating the action of gamma-aminobutyric acid (GABA), an inhibitory
neurotransmitter.
Use: Treat anxiety, panic and seizure disorders. Treat skeletal muscle spasm, acute
alcohol withdrawal and used in conscious sedation.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Significant dry mouth
or sometimes increases in salivation. Orthostatic hypotension, tinnitus. Not compatible
with pregnancy or breast-feeding.
Medical Considerations: >10%; drowsiness, ataxia, amnesia, slurred speech, lightheadedness, phlebitis, pain with injection. 1-10%; confusion, dizziness.
Other adverse reactions; insomnia, hallucinations, EKG changes, tachycardia,
hypotension, constipation, nausea, vomiting, anorexia, diarrhea, blurred vision,
mydriasis, rash, dermatitis, itching. Don’t use with narrow-angle glaucoma, preexisting CNS and respiratory depression, psychosis and severe uncontrolled pain. Use
with caution in elderly, debilitated, hepatic and renal disease.
Dental Drug Interactions: CNS depressants (alcohol, barbiturates, opiods) enhance
sedative and respiratory depressant effects of this medication. Increased effect of
medication by erythromycin and antifungals.
Medical Drug Interactions: Increased medication effect with cimetidine, cisapride,
valproic acid, antihistamines and selective serotonin reuptake inhibitors, oral
contraceptives.
Alprazolam (Xanax) Headache, taste alteration.
Diazepam (Valium)
Temazepam (Restoril)
Lorazepam (Ativan) Antiemetic, insomnia, psychogenic catatonia.
Increased
toxicity with MAO inhibitors, tricyclic antidepressants, phenothiazines.
Clorazepate (Tranxene)
Flurazepam (Dalmane) Short-term treatment of insomnia.
Triazolam (Halcion) Short-term treatment of insomnia, preoperative sedative.
20
Anti-Convulsant
 Benzodiazepines
Clonazepam (Klonopin)
Use: Treat petit mal and variant (Lennox-Gastaut), akinetic and myoclonic seizures,
restless legs syndrome, neuralgia. Multifocal tic disorder, parkinsonian dysarthria,
acute manic episodes, panic disorder and adjunct for schizophrenia.
Clonazepam Headache, blood dyscrasias.
Sedative-Hypnotic
Action: Interacts with a subunit of the GABA-benzodiazepine receptor. Same hypnotic
and anxiolytic effects as benzodiazepines, but reduced effects on skeletal muscle
relaxation and seizure activity.
Use: Short term treatment of insomnia.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Dry mouth, taste
alterations, tinnitus, headache and myalgia.
Dental Drug Interactions: Additive effect with other CNS depressants.
Zolpidem (Ambien)
Zalepion (Sonata)
Action: Binds with benzodiazepine GABA receptor complex.
Use: Short term treatment of insomnia.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Headache,
Hypesthesia, paresthesia, and myalgia.
Dental Drug Interactions: Additive effect with other CNS depressants.
Anti-Anxiety Agent
Buspirone (BuSpar)
Action: Selectively antagonizes CNS serotonin receptors, little potential for abuse.
Use: Treat anxiety and panic attacks.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Dry mouth,
paresthesias, headache, fever, blood dyscrasias and tinnitus.
Dental Drug Interactions: Increased sedation alcohol, all CNS depressants.
Hydroxyzine (Vistaril, Atarax)
Action: Depresses subcortical levels of CNS. Antagonist for histamine H-1 receptors in
GI and respiratory tracts and blood vessels.
Use: Treat anxiety, as a preoperative sedative. Also used as antipruritic, antiemetic and
in alcohol withdrawal.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Dry mouth, headache,
arthralgia and pharyngitis. Avoid in pregnancy, no data on lactation.
Medical Considerations: >10%; drowsiness, thickening of bronchial secretions. 110%; fatigue, nervousness, dizziness, appetite increase, weight gain, nausea, abdominal
pain and diarrhea.
21
Anti-Anxiety Agent
Hydroxyzine (Vistaril, Atarax)
Medical Considerations: Other adverse reactions; confusion, tremors, fatigue,
depression and convulsions.
Medical Considerations: Use with caution if narrow-angle glaucoma, prostatic
hypertrophy and bladder neck obstruction.
Dental Drug Interactions: Increased CNS depressant effects of alcohol, all CNS
depressants. Increased anticholinergic effects other antihistamines, opiod analgesics
and anticholinergics.
 Phenothiazine
Action: Causes dopaminergic neurotransmitter blockade in the cerebral cortex,
hypothalamus and limbic system and depresses hormone release. Also strong
peripheral Alpha-adrenergic blockade, anticholinergic.
Use: Psychotic disorders, mania, schizophrenia, anxiety, intractable hiccups, nausea,
vomiting, preoperative relaxation, acute intermittent porphyria, Tourette’s Syndrome
and behavior problems in children.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Dry mouth, headache,
orthostatic hypotension, laryngospasm and blood dyscrasias.
Dental Drug Interactions: Increased sedation other CNS depressants, alcohol,
barbiturates, opiod analgesics. Increased photosensitivity tetracyclines.
Chlorpromazine (Thorazine)
Fluphenazine (Prolixin) Adjunct to TCAs in neurogenic pain.
Thioridazine (Mellaril) Dementia in elderly.
Perphenazine (Trilafon) Dementia symptoms, Huntingtons chorea, spasmotic
torticollis and Reye’s syndrome.
Trifluoperazine (Stelazine)
Anti-Psychotic Agent
Risperidone (Risperdal)
Action: In CNS blocks serotonin and dopamine receptors. Peripherally blocks alpha and
histamine receptors.
Use: Manage psychotic disorders, nonpsychotic symptoms associated with dementia in
elderly.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Significant dry
mouth, stomatitis, taste alteration, orthostatic hypotension, headache, blood dyscrasias,
sinusitis and arthralgia.
Dental Drug Interactions: Increased sedation CNS depressants, additive
photosensitivity tetracyclines.
22
Anti-Psychotic Agent
Haloperidol (Haldol)
Action: Blocks neurotransmission of dopamine in cerebral cortex, hypothalamus and
limbic system. Exhibits strong peripheral alpha adrenergic and anticholinergic
blocking.
Use: Treat psychosis, Tourette’s syndrome, autism and severe behavior problems in
children. Used for emergency sedation in severely agitated or delirious patients. Treat
chemotherapy induced nausea and vomiting.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Dry mouth, sore
throat and mouth, tardive dyskinesia tongue and lip movements, headache. Orthostatic
hypotension, extrapyramidal symptoms of TMJ and laryngospasm.
Dental Drug Interactions: Barbiturates decrease effect of medication, increased
sedation with CNS depressants and increased photosensitivity with tetracyclines.
Quetiapine (Seroquel)
Action: Agonist for serotonin receptors and to lesser extent dopamine receptors.
Use: Schizophrenia
Dental Considerations: Local anesthesia with vasoconstrictor ok. Dry mouth, taste
perversion, headache, orthostatic hypotension, blood dyscrasias, ear pain, pharyngitis.
Dental Drug Interactions: Increased CNS depression with CNS depressants.
Olanzapine (Zyprexa)
Action: Antagonizing dopamine and serotonin activities.
Use: Psychotic disorders
Dental Considerations: Local anesthesia with vasoconstrictor ok. Headache, fever,
xerostomia, arthralgia.
Dental Drug Interactions: Increased sedation with CNS depressants.
Clozapine (Clozaril, Leponex)
Action: Blocks serotonin, alpha-adrenergic, histamine H-1 central nervous system
receptors, weak dopamine blocker.
Use: Schizophrenia
Dental Considerations: Local anesthesia with vasoconstrictor ok. Headache, dry mouth,
blood dyscrasias, fever, increased salivation, glossitis.
Dental Drug Interactions: Increases CNS depression all CNS depressants. Increased
anticholinergic effects anticholinergics. Erythromycin and clarithromycin may
increase clozapine concentration.
Ziprasidone (Geodon)
Action: Mixed reuptake inhibitor of serotonin and norepinephrine.
Use: Treatment of schizophrenia
Dental Considerations: Local anesthesia with vasoconstrictor ok.
Dental Drug Interactions: Additive CNS depression with other CNS depressants.
Ketoconazole increases concentration of Ziprasidone.
23
CNS Stimulant
Methylphenidate (Ritalin)
Action: Increases release of norepinephrine and dopamine in the cerebral cortex to the
reticular activating system. Stimulates cerebral cortex and subcortical structures
similar to amphetamines.
Use: Treat attention deficit disorder with hyperactivity, narcolepsy.
Dental Considerations: Local anesthesia with vasoconstrictor ok unless patient is
hypertensive. Dry mouth, headache, blood dyscrasias, and erythema multiforme.
Dental Drug Interactions: May increase effects of oral anticoagulants and barbiturates.
Pemoline (Cylert)
Action: Blocks reuptake of dopamine, acts at cerebral cortex and subcortical
levels.
Use: Attention deficit disorder with hyperactivity, narcolepsy.
Dental Considerations: Local anesthesia with vasoconstrictor ok..
Headache.
Dental Drug Interactions: None
Modafinil (Provigil)
Action: CNS stimulant, mechanism of action unknown.
Use: Narcolepsy
Dental Considerations: Local anesthesia with vasoconstrictor ok. Chills, fever, dry
mouth, oral ulcerations, gingivitis, blood dyscrasias, arthralgia, paresthesia, pharyngitis,
headache.
Dental Drug Interactions: May increase coumadin toxicity. Azole antifungals,
ketoconazole and itraconazole may increase toxicity of modafinil. May increase
valium toxicity.
 Amphetamines
Dextroamphetamine and Amphetamine (Adderall)
Dextroamphetamine (Dexedrine, Dextrostat)
Action: Blocks dopamine and norepinephrine reuptake, increasing their concentration in
cerebral cortex and reticular activating system. MAO inhibitor, causes catecholamine
release.
Use: Treat narcolepsy, obesity, abnormal behavior syndrome in children, attention
deficit/hyperactivity disorder.
Dental Considerations: No local anesthetic with vasoconstrictor, potential hypertension
and cardiotoxicity. Headache, dry mouth, unpleasant taste.
Dental Drug Interactions: Arrhythmias possible with general anesthetics.
24
 Antiobesity Agent
Orlistat (Xenical)
Action: Reversible inhibitor of lipases, prevents GI absorption of fats.
Use: Treat obesity.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Gingival and tooth
disorder, headache, TMJ-myalgia, TMJ-arthralgia.
Dental Drug Interactions: Decreases vitamin K absorption, makes warfarin more
effective.
Ergot Alkaloid
Ergoloid Mesylates (Germinal, Hydergine)
Action: May increase cerebral blood flow and metabolism.
Use: Treatment of cerebrovascular insufficiency in primary progressive dementia,
Alzheimer’s dementia, multiinfarct dementia and senile dementia.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Sublingual irritation,
orthostatic hypotension, headache.
Dental Drug Interactions: None
Ergotamine (Cafergot, Wigraine) Adrenergic blocking agent, prevent
vascular headaches, such as migraine or cluster. Dry mouth, myalgia and paresthesia.
Macrolide antibiotics may cause ergot toxicity.
Acetylcholinesterase Inhibitor
Donepezil (Aricept)
Action: Central acting reversible cholinesterase inhibitor, increases acetylcholine
concentration.
Use: Treat mild to moderate dementia associated with Alzheimer’s disease.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Toothache, dry
mouth, bad taste, gingivitis, tongue edema, coated tongue, headache, muscle
cramps, arthritis, blood dyscrasias, tinnitus.
Dental Drug Interactions: Use with NSAIDs increases risk GI bleeds. Action
decreased by anticholinergics, increases action of succinylcholine. Ketoconazole may
inhibit drugs metabolism.
Galantamine (Reminyl)
Action: Unknown, possible reversible inhibition of acetylcholinesterase.
Use: Alzheimer’s disease.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Postural
hypotension, paresthesia, dysphagia, dry mouth, blood dyscrasias.
Dental Drug Interactions: Increases activity of succinylcholine, cholinergic agonists
like bethanechol. Ketoconazole and erythromycin increases Galantamine
concentration.
25
Anti-Convulsant
Valproic Acid and Derivatives (Depacon, Depakene, Depakote)
Action: Increases levels of gamma aminobutyric acid, an inhibitory neurotransmitter, in
the brain.
Use: Simple, complex (petit mal) absence, mixed seizures, complex partial seizures,
migraine prophylaxis, tonic-clonic (grand mal) seizures and infantile spasms.
Depakote for manic episodes in bipolar disorder.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Gingival
enlargements, headache, erythema multiforme, blood dyscrasias with prolonged
bleeding and delayed healing.
Dental Drug Interactions: Increases toxicity of barbiturates, alcohol and CNS
depressants potentiates depressant effects of valproic acid. Increases bleeding with
aspirin, NSAIDs and coumadin.
Carbamazepine (Tegretol)
Action: Inhibits nerve impulses by limiting influx of sodium ions across cell membrane
in motor cortex. Also has anticholinergic, antineuralgic, antidiuretic, muscle relaxant
and antiarrhythmic properties.
Use: Treat tonic-clonic, complex-partial and mixed seizures. Trigeminal neuralgia,
bipolar and other affective disorders and resistant schizophrenia.
Alcohol withdrawal, neurogenic pain, restless leg syndrome and psychosis associated
with dementia.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Dry mouth, oral and
throat ulcers, glossitis, headache, blood dyscrasias, tinnitus and Stevens-Johnson
syndrome.
Dental Drug Interactions: Decreases effects of barbiturates, corticosteroids,
benzodiazepines, doxycycline and coumadin. Increase in carbamazepine toxicity with
erythromycin, clarithromycin, propoxyphene and antifungals.
Phenytoin (Dilantin)
Action: Inhibits spread of seizure activity in motor cortex by increasing efflux or
decreasing influx of sodium ions across cell membranes. In heart prolongs refractory
period and suppresses ventricular pacemaker automaticity, shortens action potential.
Use: Manage generalized tonic-clonic (grand mal), simple partial and complex partial
seizures, prevention of seizures following head trauma/neurosurgery. Treat ventricular
arrhythmias, including those secondary to digitalis toxicity, surgical repair of
congenital heart disease in children and prolonged Q-T interval. Also to treat
epidermolysis bullosa.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Gingival hyperplasia,
oral ulceration, taste loss, paresthesia and headache.
Blood dyscrasias, fever, Stevens Johnson syndrome and lupus
erythematosus.
Dental Drug Interactions: Decreases effects of corticosteroids, oral anticoagulants and
doxycycline. Barbiturates and chloral hydrate decrease phenytoin effects.
26
Anti-Convulsant
Gabapentin (Neurontin)
Action: Unknown
Use: Adjunct treatment of drug refractory partial and generalized seizures in adults with
epilepsy, neuropathic pain.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Dry mouth, glossitis,
gingivitis, stomatitis, pharyngitis, blood dyscrasias and myalgia.
Dental Drug Interactions: None
Felbamate (Felbatol)
Action: Unknown
Use: Alone or as adjunct in partial seizures. Also for partial seizures in children with
Lennox-Gastaut syndrome.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Gingival bleeding
and hyperplasia (not with monotherapy), dry mouth, facial edema, buccal mucosa
swelling, blood dyscrasias and headache.
Dental Drug Interactions: None
Topiramate (Topamax)
Action: Action unclear, increases GABA activity, blocks repetitive action potentials and
non-NMDA receptors.
Use: Adjunctive therapy for adult partial onset seizures, Lennox-Gastaut syndrome,
primary generalized tonic-clonic seizures.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Dry mouth, taste
alteration, gingival hyperplasia, gingivitis, sinusitis, blood dyscrasias, photophobia,
myalgia, paresthesia, hypoesthesia.
 Barbiturates
Action: Interferes with transmission of impulses from the thalamus to the cerebral cortex
resulting in an imbalance in central inhibitory and facilitatory mechanisms. A CNS
depressant.
Use: All forms of epilepsy, status epilepticus, febrile seizures in children, sedation,
insomnia, hyperbilirubinemia and chronic cholestasis.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Headache, fever,
laryngospasm, Stevens-Johnson syndrome and blood dyscrasias.
Dental Drug Interactions: Decreases effects of corticosteroids, oral anticoagulants and
doxycycline. Enhances sedative properties of propoxyphene, benzodiazepines and
CNS depressants.
Phenobarbital (Barbita)
Mephobarbital (Mebaral) Tinnitus
Primidone (Myosoline)
27
Anti-Convulsant
Levetiracetam (Keppra)
Action: Unknown
Use: Adjunctive therapy for treatment of partial onset adult seizures.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Headache,
paresthesia, sinusitis, arthralgia, and gingivitis.
Dental Drug Interactions: None.
Primidone (Mysoline)
Action: Increases seizure threshold, decreases neuron excitability, broken down into
phenobarbital.
Use: Treat grand mal, complex partial and focal seizures.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Headache, blood
dyscrasias, lupus-like syndrome.
Dental Drug Interactions: Additive CNS depression with other CNS depressants, liver
damage with halogenated inhalation general anesthetics, decreases effects of
acetaminophen, corticosteroids, Doxycycline and NSAIDs.
Oxcarbazepine (Trileptal)
Action: Blocks sodium channels, stabilizes neuronal membranes, depresses synaptic
impulses.
Use: Treat partial seizures.
Dental Considerations: Local anesthesia with vasoconstrictors ok. Headache, fever,
postural hypotension, Dysphagia, gingival hyperplasia and bleeding, dry mouth,
stomatitis, blood dyscrasias, photosensitivity, photophobia, altered taste, TMJ-tinnitus.
Dental Drug Interactions: None.
Anti-Parkinson Agent
Levodopa and Carbidopa (Sinemet)
Action: Parkinson’s symptoms are due to lack of dopamine in brain. Levodopa crosses
blood brain barrier where it is converted to dopamine. Carbidopa inhibits the
peripheral plasma breakdown of levodopa.
Use: Treatment of idiopathic, symptomatic or postencephalitic Parkinsonism.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Dry mouth, bitter
taste, headache, paresthesia, orthostatic hypotension and blood dyscrasias.
Dental Drug Interactions: Decreases effects of benzodiazepines.
Pergolide Mesylate (Permax)
Action: Semisynthetic ergot alkaloid, centrally acting dopamine agonist.
Use: Adjunct to Levodopa and Carbidopa to manage Parkinson’s disease.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Postural
hypotension, chills, dry mouth.
Dental Drug Interactions: None.
28
Anti-Parkinson Agent
Pramipexole (Mirapex)
Action: Pre- and postsynaptic dopamine agonist.
Use: Treat signs and symptoms of Parkinson’s Disease.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Postural
hypotension, hyperesthesia, and dry mouth.
Dental Drug Interactions: None
Selegiline (Eldepryl)
Action: MAO inhibitor, MAO causes dopamine metabolism. May also interfere with
dopamine reuptake.
Use: Treat Parkinson patients where levodopa/carbidopa not working.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Dry mouth and
orthostatic hypotension.
Dental Drug Interactions: Don’t use with Demerol, serotonin syndrome.
Benztropine (Cogentin)
Action: Blocks central acetylcholine receptors. Helps balance cholinergic and
dopaminergic activity.
Use: Treat Parkinson symptoms and extrapyramidal symptoms associated with
neuroleptic drugs.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Dry mouth, nose and
throat, glossitis. Sometimes increased salivation.
Dental Considerations: Headache, difficulty swallowing, photophobia, orthostatic
hypotension and elevated temperature.
Dental Drug Interactions: Increased anticholinergic effects with antihistamines,
meperidine and other anticholinergics. Increased CNS depression with alcohol and
other CNS depressants.
Rivastigmine (Exelon)
Action: Reversible inhibition of hydrolysis of cholinesterase, increases
acetylcholinesterase concentration in the CNS.
Use: Dementia due to Alzheimer’s disease.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Headache,
pharyngitis, Stevens-Johnson syndrome.
Dental Drug Interactions: May increase risk of ulcers with NSAIDs. Reduces effects
of anticholinergics. Increases effects of cholinergics
Ropinirole (ReQuip)
Action: Dopamine receptor agonist in the brain.
Use: Parkinson’s disease.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Dry mouth,
headache, postural hypotension, blood dyscrasias, pharyngitis.
Dental Drug Interactions: Increased sedation with other CNS depressants.
29
Anti-Parkinson Agent
Amantadine (Cyclocort)
Action: Works as antiviral by uncoating of influenza A virus to prevent penetration into
host, as antiParkinson by blocking dopamine reuptake and stimulation of postsynaptic
neurons.
Use: Treat Parkinson’s disease, influenza A virus, and drug induced extrapyramidal
symptoms.
Dental Consideration: Local anesthesia with vasoconstrictor ok. Dry mouth,
orthostatic hypotension, headache, blood dyscrasias.
Dental Drug Interactions: Anticholinergics increase CNS side effects of amantadine.
Anti-Migraine Agent
 Serotonin Agonist
Action: Selective agonist for serotonin receptor in cranial arteries causing vasodilatation
with little or no effect on peripheral pressure.
Use: Acute treatment of migraine headaches with or without aura. Also to treat cluster
headaches.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Mouth, jaw, tongue,
throat and sinus discomfort.
Dental Considerations: Headache, photophobia and myalgia. Paresthesia with tingling,
hot or burning sensation, numbness.
Dental Drug Interactions: None
Sumatriptan (Imitrex)
Zomitriptan (Zomig)
Rizatriptan (Maxalt)
Naratriptan (Amerge)
Thyroid Hormone
Action: Stimulates protein synthesis, increases basal metabolic rate, utilization glucose
and growth.
Use: Hypothyroid, myxedema coma, thyroid hormone replacement and cretinism.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Headache, myalgia
and fever.
Dental Drug Interactions: Increases effect of oral anticoagulants.
Levothyroxine, T 4, (Synthroid, Levoxyl)
Liotrix, T 4 & T 3, (Euthroid, Thyrolar)
Liothyronine, T 3, (Cytomel, Triostat)
30
Gastric Acid Secretion Inhibitors
 Histamine-2 (H-2) Antagonist
Action: Inhibits histamine at H-2 receptor sites of gastric parietal cells, decreased gastric
acid secretion.
Use: Treat and prophylaxis of duodenal and gastric ulcers, treat gastroesophageal reflux,
upper GI bleed, hypersecretory conditions, stress ulcers, GI symptoms secondary to
NSAIDs.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Headache, arthralgia,
blood dyscrasias, angioneurotic edema and fever.
Dental Drug Interactions: Decreased absorption of ketoconazole, itraconazole and
valium, increased toxicity of versed. Variable effects on warfarin.
Ranitidine (Zantac)
Cimetidine (Tagamet) Decreases tetracycline absorption, increases blood levels
alcohol, diazepam and narcotic analgesics.
Nizatidine (Axid) #92 in 97’
Famotidine (Pepcid) #50 in 97’ Dry mouth, taste changes, paresthesia, tinnitus,
myalgia
 Proton Pump Inhibitor
Action: Gastric parietal cell pump inhibited less gastric acid secretion.
Use: Treat peptic and gastric ulcer disease, severe erosive esophagitis, gastroesophageal
reflux disease, hypersecretory conditions and NSAID induced ulcers.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Headache, dry mouth,
taste alterations, mucosal atrophy of tongue, candidiasis, tinnitus, myalgia, arthralgia
and fever.
Dental Drug Interactions: Decreased effect of ketoconazole and itraconazole, increased
effect of valium, coumadin.
Omeprazole (Prilosec)
Lansoprazole (Prevacid)
Rabeprazole (Aciphex) facial edema, gingivitis, glossitis, paresthesia,
photosensitivity, salivary gland enlargement
Pantoprazole (Protonix)
Esomeprazole (Nexium)
Anti-Inflammatory Agent
Sulfasalazine (Azulfidine)
Action: Sulfasalazine has high affinity for connective tissue and serous fluid, liver and
intestinal walls. The principle metabolites of this sulfonamide derivative are
sulfapyridine and 5-aminosalicyclic acid (the anti-inflammatory agent).
Use: Treat ulcerative colitis, Crohn’s disease and rheumatoid arthritis.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Headache, fever,
chills, Stevens-Johnson syndrome, blood dyscrasias.
31
Anti-Inflammatory Agent
Sulfasalazine (Azulfidine) (continued)
Dental Drug Interactions: Decreases effect of oral anticoagulants, ester type local
anesthetics (procaine, tetracaine) and penicillins and cephalosporins. Increases
tetracycline photosensitizing effect.
Mesalamine (Asacol, Pentasa, Rowasa)
Action: 5-aminosalicyclic acid, works topically to modulate chemical mediators of
inflammation.
Use: Treat ulcerative colitis, proctosigmoiditis, and proctosis.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Headache, blood
dyscrasias.
Dental Drug Interactions: None
GI Anticholinergic
Action: Blocks action of acetycholine at parasympathetic sites in smooth muscle,
secretory glands and the CNS. Functions as GI antispasmodic agent.
Use: Treat irritable bowel syndrome, urinary incontinence, infant colic, in combination
with other drugs for peptic ulcer disease.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Dry mouth, throat
and nose, headache, dysphagia, photophobia, fever and orthostatic hypotension.
Dental Drug Interactions: Increases toxicity of narcotics, antihistamines, other
anticholinergics. Decreases effects of ketoconazole.
Dicyclomine (Bentyl, Antispas)
Clidinium** and Chlordiazepoxide* (Librax) *Is the benzodiazepine
Librium **Taste alterations
Hyoscyamine (Levbid)
Cholinergic
Action: Inhibits destruction of acetylcholine thus increasing acetylcholine concentration.
Use: Nondepolarizing muscle relaxant antagonist, myasthenia gravis.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Salivation, tongue
weakness, headache, bronchospasm and laryngospasm.
Dental Drug Interactions: Decreases effects of anticholinergics. Reduces rate of
metabolism of ester local anesthetics.
Pyridostigmine (Mestinon)
32
Monoclonal Antibody
Action: Binds to an inflammatory cytokine.
Use: Treat rheumatoid arthritis and Crohn’s disease.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Candidiasis,
headache, fever, TMJ-myalgia, pharyngitis, sinusitis.
Dental Drug Interactions: None
Infliximab ( Remicade)
Anti-Emetic
Metoclopramide (Reglan)
Action: Blocks dopamine receptors in chemoreceptor trigger zone of CNS.
Enhances response to acetylcholine in upper GI tract enhancing motility and gastric
emptying without simultaneous gastric, biliary or pancreatic secretion.
Use: Treat diabetic gastric stasis, gastroesophageal reflux, prevent nausea from
chemotherapy, radiation and post surgery.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Dry mouth, headache
and blood dyscrasias.
Dental Drug Interactions: Decreased GI action with anticholinergics, opiods.
Increased sedation with alcohol and other CNS depressants.
Dronabinol (Marinol)
Action: Probably inhibits vomiting center in medulla oblongata
Use: When conventional antiemetics fail to relieve nausea and vomiting associated with
cancer chemotherapy, AIDs related anorexia
Dental Considerations: Local anesthesia with vasoconstrictor ok. Orthostatic
hypotension, headache, dry mouth, paresthesia, myalgia and tinnitus.
Dental Drug Interactions: Increased drowsiness with alcohol, barbiturates and
benzodiazepines.
Antacid
Dihydroxyaluminum Sodium Carbonate (Rolaids)
Action: Neutralizes stomach acid.
Use: Relief of upset stomach due to hyperacidity.
Dental Considerations: Local anesthesia with vasoconstrictor ok.
Dental Drug Interactions: Decreases absorption of ketoconazole and itraconazole.
Antacid +
 Calcium Product
Action: Neutralizes gastric acidity, supplies calcium which is needed for muscle
contraction, bone formation and combines with dietary phosphate to form insoluble
calcium phosphate which is excreted in feces.
Use: Treatment and prevention of calcium depletion (osteoporosis, osteomalacia),
control of hyperphosphatemia in end stage renal disease and as antacid.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Myalgia.
33
Antacid +
 Calcium Product (continued)
Dental Drug Interactions: Decreases tetracycline, anticholinergic, ketoconazole and
sodium fluoride absorption.
Calcium Carbonate (Tums)
Antacid +
 Magnesium Salt
Action: Reacts with hydrochloric acid in stomach to form magnesium chloride.
Promotes bowel evacuation by causing osmotic retention of fluid, which distends the
colon and results in increased peristaltic activity.
Use: Short term treatment of constipation and symptoms of hyperacidity. Magnesium
replacement therapy.
Dental Considerations: Local anesthesia with vasoconstrictor ok.
Dental Drug Interactions: Decrease absorption of tetracyclines and indomethacin.
Magnesium Hydroxide (Milk of Magnesia)
Laxative
Action: Bulk producer, stool softener, works by absorbing water into intestine, which
promotes peristalsis.
Use: Treat constipation
Dental Considerations: Local anesthesia with vasoconstrictor ok.
Dental Drug Interactions: None
Docusate (Colace) Leaves bitter taste causes sore throat.
Psyllium (Metamucil) Decreases effect of coumadin, salicylates and
tetracycline. Treat irritable bowel syndrome also.
Calcium Polycarbophil (FiberCon) Decreases effect of tetracycline. Can
use to treat diarrhea or constipation.
Laxative
Action: Irritates smooth muscle of intestine stimulating peristalsis. Also promotes water
and electrolyte secretion into the intestine.
Use: Treat constipation, colonic evacuation prior to surgery or examination.
Dental Considerations: Local anesthesia with vasoconstrictor ok.
Dental Drug Interactions: Decreases effect of oral anticoagulants.
Bisacodyl (Fleet, Dulcolax enemas)
Antidiarrheal
Diphenoxylate and Atropine (Lomotil)
Action: Inhibits gastric motility by acting on mucosal receptors responsible for
peristalsis. Narcotic related to meperidine. Atropine in to discourage abuse.
Use: Simple diarrhea.
34
Antidiarrheal (continued)
Diphenoxylate and Atropine (Lomotil)
Dental Considerations: Local anesthesia with vasoconstrictor ok. Dry mouth and
headache.
Dental Drug Interactions: Increased effects of alcohol, CNS depressants, opiod
analgesics and anticholinergics.
Antidiarrheal
Loperamide (Imodium)
Action: Slows intestinal motility and effects water and electrolyte movement through the
bowel.
Use: Control and symptomatic relief of acute nonspecific diarrhea, including traveler’s
diarrhea.
Dental Considerations: Local anesthesia with vasoconstrictor ok.
Dental Drug Interactions: None
Colon Acidifier
Action: Bacteria degradation of lactulose in the colon acidifies colonic contents. This
results in ammonium ion retention in the colon and its excretion with a net decrease in
blood ammonium concentration.
Use: Prevention and treatment of portal-systemic encephalopathy, including the stages of
hepatic pre-coma and coma.
Dental Considerations: Local anesthetic with vasoconstrictor ok.
Dental Drug Interactions: None.
Lactulose (Cephulac, Duphalac)
Pancreatic Enzymes
Lipase, Amylase and Protease (Creon 10)
Action: Lipase breaks downs fat, amylase breaks down starch and protease breaks down
protein for digestive purposes.
Use: Treat pancreatic exocrine insufficiency.
Dental Considerations: Local anesthesia with vasoconstrictor ok.
Dental Drug Interactions: None
Estrogen
Action: Hormone required for the development, maintenance and adequate function of
the female reproductive system. Does this by increasing synthesis of DNA, RNA and
selective proteins.
35
Estrogen (continued)
Also decreases the release of gonadotropin-releasing hormone, inhibits ovulation and
helps maintain bone structure.
Use: Treat menopause, breast cancer, prostatic cancer, abnormal uterine bleeding,
hypogonadism, ovariectomy, primary ovarian failure, prophylactic for osteoporosis.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Headache,
exacerbates gingivitis and gingival bleeding. Increases alveolitis after tooth extraction.
Dental Drug Interactions: Increases action of corticosteroids. Increases potential for
thromboembolic events with anticoagulants by decreasing anticoagulant effect. Oral
antibiotic may decrease estrogen effect.
Estrogens, conjugated (Premarin)
Estradiol (Estrace, Estraderm, Climara)
Estropipate (Ortho-Est, Ogen)
Progestogen
Action: Hormone, which inhibits the secretion of pituitary gonadotropins. This prevents
follicular maturation and ovulation. Also stimulates growth of mammary tissue.
Use: Abnormal uterine bleeding, secondary amenorrhea, endometrial cancer, metastatic
renal cancer, as a contraceptive. Used with estrogens to reduce incidence of
endometrial cancer.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Gingival bleeding,
gingival overgrowth, fever.
Dental Drug Interactions: No problems with antibiotics, only effect estrogens.
Medroxyprogesterone (Provera, Cycrin, Depo-Provera)
Norethindrone (Aygestin, Micronor, Nor-QD, Femhrt)
Progesterone (Progestasert, Prometrium)
Estrogen +
 Estrogen and Progestin Combination
Action: Suppress gonadotropins and thus inhibit ovulation.
Use: Treat vasomotor symptoms of menopause, atrophic vaginitis, primary ovarian
failure, prophylactic for osteoporosis, prevent pregnancy.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Gingivitis, gingival
bleeding, headache, fever. Increased alveolitis post tooth extraction.
Dental Drug Interactions: If give oral antibiotic must use different method of birth
control until next menses. Barbiturates decrease effect of this medication, increases
toxicity of Tylenol, anticoagulants, benzodiazepines, and corticosteroids.
Estrogen and Medroxyprogesterone (Prempro, Premphase)
Ethinyl Estradiol and Norethindrone (Ortho-Novum, Loestrin,
Loestrin Fe, Norinyl)
Ethinyl Estradiol and Norgestrel (Lo/Ovral)
36
Estrogen +
 Estrogen and Progestin Combination (continued)
Ethinyl Estradiol and Norgestimate (Ortho Tri-Cyclen)
Ethinyl Estradiol and Levonorgestrel (Triphasil, Levlen, TriLevlen, Levlite)
Ethinyl Estradiol and Desogestrel (Desogen, Orthocept)
Ethinyl Estradiol and Ethynodiol Diacetate (Demulen)
 Estrogen and Androgen Combinations
Action: Estrogen is hormone for growth, development and maintenance of the female
reproductive system.
Androgen is hormone which stimulates receptors in organs and tissues to
promote growth and development of male sex organs and maintain secondary sex
characteristics in androgen deficient males.
Use: Atrophic vaginitis, hypogonadism, primary ovarian failure, vasomotor symptoms of
menopause, prostatic carcinoma and prophylaxis for osteoporosis.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Increased alveolitis
post tooth extraction. Gingivitis, gingival bleeding, blood dyscrasias and headache.
Dental Drug Interactions: Decreases effect of oral anticoagulants. Increases insulin
requirement. Increases action of corticosteroids. Oral antibiotics may decrease
estrogen effect.
Estrogen and Methyltestosterone (Estratest)
SERM
 Selective Estrogen Receptor Modulator
Action: Effects some of the same receptors as estrogen, but not all. Acts like estrogen to
prevent bone loss and improve lipid profiles but has potential to block estrogen effects
such as those causing breast and uterine cancer.
Use: Prevention of osteoporosis in postmenopausal women.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Sinusitis, pharyngitis,
arthralgia, myalgia.
Dental Drug Interactions: None reported yet of clinical significance.
Raloxifene (Evista)
Gonadotropin Releasing Hormone
Action: Suppresses ovarian and testicular steroidogensis due to decreased levels of LH
and FSH. Decreases levels of testosterone (male) and estrogen (female) hormones.
Use: Treat precocious puberty. Palliative treatment of advanced prostate carcinoma.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Headache,
paresthesia and myalgia.
Dental Drug Interactions: None
Leuprolide (Lupron)
37
Anti-Histamine
Action: Competes with histamine for H-1 receptor sites in GI tract, blood vessels and
respiratory tract. Net result is a decreased allergic response.
Use: Relief of nasal and non-nasal symptoms of seasonal allergic rhinitis (sneezing,
rhinorrhea, lacrimation and pruritis) and chronic urticaria.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Headache, dry mouth,
altered taste, increased thickness of secretions, arthralgia, myalgia, tinnitus and
paresthesias.
Dental Drug Interaction: Increased CNS depression with CNS depressants and alcohol.
Increased anticholinergic effects with anticholinergics and other antihistamines.
Don’t use ketoconazole or erythromycin with this medication, can result in liver damage
and cardiac arrhythmias.
Loratadine (Claritin)
Terfenadine (Seldane) No longer sold, cardiac arrhythmias and fatalities when
used with erythromycin and antifungals.
Astemizole (Hismanal) Blood dyscrasias, increases photosensitivity of
tetracyclines. Taken off market in June 1999 for same reasons as Seldane.
Cetirizine (Zyrtec) Tongue edema, orofacial dyskinesia, blood dyscrasias.
Fexofenadine (Allegra) Doesn’t cross blood brain barrier, little sedation.
Clemastine (Tavist)
Diphenhydramine (Benadryl) Also used to treat motion sickness,
Parkinson’s disease, phenothiazine induced dystonic reactions, infant colic,
nonproductive cough, used for nighttime sedation. Can also be used as local
anesthetic. Blood dyscrasias.
Meclizine (Antivert) Nonspecific CNS depressant with anticholinergic and
antihistamine activity blocks middle ear neural activity. Used to treat vertigo and
motion sickness.
Promethazine (Phenergan) as a suppository. A phenothiazine derivative,
mainly acts as antihistamine. Also used as antiemetic, to treat motion sickness and as
a pre and postoperative sedative.
Azatadine (Optimine)
Chlorpheniramine (Chlor-Trimeton)
Decongestant
 Adrenergic Agonist Agent
Action: Primarily stimulates alpha-adrenergic receptors of respiratory mucosa causing
vasoconstriction. Also stimulates beta-adrenergic receptors causing bronchial
relaxation, increased heart rate and contractility.
Use: Temporary symptomatic relief of nasal congestion due to common cold, upper
respiratory allergies and sinusitis. Also promotes nasal and sinus drainage.
Dental Considerations: Don’t use local anesthetic with vasoconstrictor, can cause
pressor response. Dry mouth, headache.
38
Decongestant
 Adrenergic Agonist Agent (continued)
Dental Drug Interactions: Hypertensive crisis with MAO inhibitors, sympathomimetics.
Sedation with CNS depressants and alcohol. Arrhythmias with inhalation anesthetics.
Pseudoephedrine (Sudafed, Actifed Tabs, Afrin Tabs,
Triaminic)
Oxymetazoline (Afrin) Treat middle ear infections, redness of eye. Rebound
congestion with prolonged use.
Ephedrine Also treat bronchial asthma and bronchospasm, orthostatic hypotension.
Releases tissue stores of epinephrine. Longer acting but less potent than epinephrine.
Use with atropine will increase blood pressure
.
Anti-Histamine +
 Combined with Decongestant
Action: Antihistamine decreases allergic reaction. Adrenergic agonist causes
vasoconstriction of respiratory mucosa.
Use: Treat nasal and sinus congestion.
Dental Considerations: No local anesthetic with vasoconstrictor. Rest same as
antihistamines and decongestants.
Dental Drug Interactions: Same as antihistamines and decongestants. Most important,
don’t use erythromycin with these medications.
Loratadine and Pseudoephedrine (Claritan D)
Brompheniramine and Phenylpropanolamine (Dimetapp)
 Combined with Antitussive
Promethazine and Codeine (Phenergan with Codeine)
Action: Promethazine, which is also a Phenothiazine derivative, primarily functions as a
antihistamine. Codeine, an opium alkaloid, is also a narcotic analgesic. At the smaller
doses, used here, it primarily exerts an antitussive effect by suppressing the CNS
medullary cough center.
Use: Temporary relief of cough and upper respiratory symptoms associated with allergy
or common cold.
Dental Considerations: Local anesthesia with vasoconstrictor ok. In dosages used no
problems reported.
Dental Drug Interactions: In dosages used none reported.
39
+ Decongestant
 Analgesic and Decongestant
Acetaminophen* and Pseudoephedrine (Tylenol Sinus,
Allerest, Dristan, Sinarest)
Action: Acetaminophen is analgesic and antipyretic, not anti-inflammatory.
Pseudoephedrine is adrenergic agonist decongestant.
Use: Relief of congestion with mild to moderate pain.
Dental Considerations: No local anesthesia with vasoconstrictor. *Dry mouth,
headache, blood dyscrasias, don’t use with G6PD deficiency.
Dental Drug Interactions: *Can cause hepatic toxicity in therapeutic doses with
alcoholics and with INH. Large doses cause hepatitic toxicity with barbiturates and
Dilantin. Rest same as decongestants.
+ Anti-Histamine +
 Analgesic, Antihistamine and Decongestant
Acetaminophen, Chlorpheniramine and Pseudoephedrine
(Sinutab)
Action: Analgesic, antihistamine and decongestant.
Use: Temporary relief of sinus symptoms.
Important Dental Considerations: Say no to local anesthesia with vasoconstrictors.
Say no to alcoholics, if taking INH, erythromycin and antifungal medications.
Expectorant
Guaifenesin (Robitussin)
Action: Irritates gastric mucosa and stimulates respiratory tract secretions thus
increasing respiratory fluid volumes and decreasing phlegm viscosity.
Use: Temporary control of cough due to minor throat and bronchial irritation.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Headache.
Dental Drug Interactions: None
Iodinated Glycerol (Organidin)
Action: Increases respiratory tract secretions by decreasing surface tension and thereby
decreases mucous viscosity, which aids in removal of mucous.
Use: Adjunctive treatment of bronchitis, bronchial asthma, pulmonary emphysema,
cystic fibrosis and chronic sinusitis.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Headache.
Dental Drug Interactions: Increases toxicity of Flagyl, CNS depressants.
40
Expectorant +
 Combined with Antitussive
Guaifenesin and Dextromethorphan (Robitussin DM)
Action: Expectorant and *chemical relative of morphine lacking narcotic properties at
dose used. Antitussive through medullary cough center depression.
Use: Temporary control of cough due to minor throat and bronchial irritation.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Headaches.
Dental Drug Interactions: None
 Combined with Decongestant
*Guaifenesin and **Phenylephrine (Deconsal, Sinupan)
*Guaifenesin and **Pseudoephedrine (Entex)
Action: * Phlegm volume increased, viscosity decreased. **Decreases blood flow to
respiratory mucosa.
Use: Cold preparation.
Dental Considerations: Don’t use local anesthesia with vasoconstrictor. Dry mouth,
headache.
Dental Drug Interactions: Hypertensive crisis with MAO inhibitors, sympathomimetics.
Sedation with CNS depressants and alcohol. Arrhythmias with inhalation anesthetics.
 Combined with Decongestant
Guaifenesin and Phenylpropanolamine (Triaminic
Expectorant)
Use: Relief of respiratory conditions with tenacious mucous plugs and congestion. Used
in sinusitis, pharyngitis, bronchitis, asthma. Adjunctive therapy in serous otitis media.
Action, Dental Considerations, Dental Drug Interactions: Same as individual
components.
Insulin Preparations
Action: Pancreatic hormone causing glucose to enter cells. Promotes conservation of
energy as glucose is converted to glycogen (in muscle and liver cells) and triglycerides
(in fat cells). Fat mobilization and gluconeogenisis is inhibited, protein synthesis is
stimulated.
Use: Treat insulin dependent diabetes mellitus, IDDM, (juvenile onset, type I). Also for
noninsulin dependent diabetes mellitus, NIDDM, (insulin independent, maturity onset,
type II) unresponsive to diet and or oral hypoglycemics. With glucose to treat
hyperkalemia. Also to reduce glycosuria in patients getting hyperalimentation.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Dry mouth, numbness
of mouth, headache and hypothermia. If IDDM consider antibiotic prophylaxis with
surgery, more prone to infection. Patient should monitor blood sugar and vary
insulin dosage accordingly following dental procedures which alter oral intake. May
have delayed or poor healing.
41
Insulin Preparations (continued)
Dental Drug Interactions: Salicylates and NSAIDs (large doses, chronic use), alcohol
and tetracyclines increase hypoglycemic effect. Steroids and smoking decrease
hypoglycemic effect.
 Rapid onset (1/2 - 1 hour), short duration (10 - 24 hours).
Regular Insulin (Novolin R, Humulin R)
Prompt Insulin Zinc Suspension, Semilente
Isophane Insulin and Regular Insulin (Novolin 70/30)
 Intermediate Acting, onset (1 - 2 1/2 hours), duration (18 - 24 hours)
Insulin Zinc Suspension, NPH, (Novolin N, Humulin N)
Isophane Insulin Suspension, Lente
 Long Acting, onset (4 - 8 hours), duration (36 hours or more)
Protamine Zinc Insulin Suspension, PZI
Extended Insulin Zinc Suspension, Ultralente (Humulin U)
Oral Anti-Diabetic Agent
 Sulfonylurea
Action: Stimulates release of insulin from pancreatic beta cells. Increases insulin
sensitivity at peripheral target sites. Reduces liver output of glucose.
Use: Control blood sugar in adult onset, noninsulin dependent diabetes (type II). Also
treat neurogenic diabetes insipidus.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Headaches, tinnitus,
blood dyscrasias.
Dental Drug Interactions: Salicylates increase hypoglycemic response. Can act like
antabuse with alcohol.
Chlorpropamide (Diabinese) 1st generation
Glimepiride (Amaryl) 2nd generation
Glipizide (Glucotrol) 2nd generation
Glyburide (Diabeta, Glynase, Micronase) 2nd generation, joint pain
 Biguanides
Action: Decreases hepatic glucose production decreases intestinal absorption of glucose
and improves peripheral insulin sensitivity (increases glucose uptake and utilization).
Use: Management of noninsulin dependent diabetes mellitus type II, either alone or
concomitantly with a sulfonylurea.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Unpleasant metallic
taste, blood dyscrasias.
Dental Drug Interactions: Corticosteroids decreases effect, can cause hyperglycemia.
Morphine and vancomycin increases effect can cause hypoglycemia.
42
Oral Anti-Diabetic Agent
 Biguanides (continued)
Metformin (Glucophage)
 Sulfonylurea and Biguanides
Glyburide and Metformin (Glucovance)
Action, Use, Dental Considerations an d Dental Drug Interactions: See individual
drugs.
 Meglitinide
Repaglinide (Prandin)
Nateglinide (Starlix)
Action: Stimulates insulin secretion by beta cells of pancreas.
Use: Adjunct to diet and exercise to lower blood glucose in non-insulin dependent, Type
II diabetes mellitus.
Dental Considerations: Local anesthesia with vasoconstrictor ok..
Dental Drug Interactions: None.
 Thiazolidinedione Derivative
Pioglitazone (Actos)
Rosiglitazone (Avandia)
Troglitazone (Rezulin) Withdrawn from market March 2000
Action: Improves target cell sensitivity to insulin, mainly peripherally, skeletal muscle
and adipose tissue, not as effective on liver. No effect on pancreas.
Use: Manage type II diabetics currently on insulin whose hyperglycemia is not
controlled. Also can be used as monotherapy or in combination with sulfonylureas and
Metformin.
Dental Considerations: Local anesthesia with vasoconstrictors ok. Headache, neck
pain, pharyngitis, infection and sinusitis.
Dental Drug Interactions: Ketaconazole and itraconazole increase effect of this
medication.
 Alpha Glucosidase-Inhibitor
Acrobase (Procase)Rosiglitazone (Avandia)
Action: Competitive, reversible inhibition of pancreatic enzyme alpha-amylase and
intestinal membrane bound alpha gluosidase hydrolase enzyme, delays glucose
absorption and lowers blood glucose.
Use: Manage type II diabetics currently on insulin whose hyperglycemia is not
controlled. Also can be used as monotherapy or in combination with sulfonylureas and
Metformin.
Dental Considerations: Local anesthesia with vasoconstrictors ok.
Dental Drug Interactions: Increased hypoglycemia with corticosteroids.
43
Calcium Salt
Action: Needed for nerve and muscle performance via action potential excitation
threshold regulation. Also deposited in bone formation. Neutralizes gastric acidity.
Use: Prevent postmenopausal osteoporosis. Treat and prevent calcium depletion.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Headache.
Dental Drug Interactions: Decreases absorption of tetracyclines.
Calcium Citrate (Citracal)
Biphosphonate Derivative
Action: Inhibits osteoclastic mediated bone resorption.
Use: Treatment and prevention of osteoporosis in postmenopausal women. Also treat
Paget’s disease of bone, osteolytic bone metastases.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Taste alteration,
headache, dysphagia, tinnitus, paresthesia and muscle pain.
Dental Drug Interaction: Increases risk of GI side effects with NSAIDs and ASA.
Alendronate (Fosamax)
Risedronate (Actonal)
Calcitonin Product
Action: Hormone, which inhibits osteoclastic bone resorption. Promotes renal excretion
of calcium, phosphate, sodium, magnesium and potassium by decreasing tubular
reabsorption. Increases jejunal secretion of water, sodium, potassium and chloride.
Use: Treat Postmenopausal osteoporosis, as adjunct for hypercalcemia, for Pagets
disease of bone and intractable bone pain.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Dry mouth, metallic
taste, facial flushing, headache, paresthesia, chills, myalgia and arthrosis.
Dental Drug Interactions: None
Calcitonin (Miacalcin Nasal Spray)
Uric Acid Lowering Agents
Allopurinol (Zyloprim)
Action: Inhibits the enzyme xanthine oxidase reducing uric acid synthesis.
Use: Treat chronic gout, hyperuricemia associated with malignancies, recurrent calcium
oxalate calculi.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Metallic taste,
stomatitis, salivary gland swelling, Stevens-Johnson syndrome, paresthesia, headache,
arthralgia, blood dyscrasias, chills and fever.
Dental Drug Interactions: May increase incidence of skin rash with ampicillin and
amoxicillin. Increases activity of oral anticoagulants.
44
Colchicine
Action: Decreases leukocyte motility, phagocytosis in joints, lactic acid production,
reduces uric acid crystals.
Use: Treat gout, manage familial Mediterranean fever.
Dental Considerations: Local anesthesia with vasoconstrictor ok.
Dental Drug Interactions: Additive effect with CNS depressants.
Antiglaucoma Agent
 Noncardioselective Beta Blocker
Action: Blocks both beta-1 and beta-2 adrenergic receptors. Reduces intraocular
pressure by reducing aqueous humor production or possibly outflow.
Use: Treat elevated intraocular pressure such as glaucoma or ocular hypertension.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Headache.
Dental Drug Interactions: None
Timolol (Timoptic) Eye drops.
Levobunolol (Betagan)
 Beta 1 Adrenergic Blocker
Action: Reduces production of aqueous humor and thus reduces intraocular pressure.
Use: Treat chronic open angle glaucoma and ocular hypertension.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Headache.
Dental Drug Interactions: None
Betaxolol (Betoptic) Eye drops.
Antiglaucoma Agent
 Diuretic, Carbonic Anhydrase Inhibitor
Action: Inhibits this enzyme, which results in less hydrogen ion secretion at renal tubule
and increased renal excretion of sodium, potassium, bicarbonate and water.
Action: Decreases production of aqueous humor. In CNS retards abnormal and
excessive neuron discharge.
Use: Open angle and narrow angle glaucoma, epilepsy, edema in CHF, drug-induced
edema and acute altitude sickness.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Metallic taste, dry
mouth, blood dyscrasias, paresthesia, fever, paresthesia, tinnitus and Stevens-Johnson
syndrome.
Dental Drug Interactions: Toxicity with large dose salicylates. Hypokalemia with
corticosteroids.
Acetazolamide (Diamox)
Dorzolamide (Trusopt) Eye drops, only to treat glaucoma.
Methazolamide (GlaucTabs)
Photophobia.
45
Antiglaucoma Agent
 Cholinergic (Parasympathetic) Agent
Action: Directly stimulates cholinergic receptors in the eye causing miosis (contraction
of iris sphincter). Also causes loss of accommodation and lowering of intraocular
pressure by decreasing resistance to aqueous humor outflow.
Use: Management of chronic simple glaucoma, chronic and acute angle closure
glaucoma, counter effects of mydriatics.
Dental Considerations: Local anesthesia with vasoconstrictors ok. Headache,
photophobia, excessive salivation.
Dental Drug Interactions: May antagonize effects of anticholinergics.
Pilocarpine (Isopto)
 Prostaglandin Analogue
Action: Reduces intraocular pressure by increasing uveoscleral outflow of aqueous
humor.
Use: Open angle glaucoma and ocular hypertension in patients intolerant to other
intraocular pressure lowering drugs.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Myalgia, arthralgia
and photophobia.
Dental Drug Interactions: Avoid anticholinergics.
Latanoprost (Xalatan) Eye drops.
 Alpha 2 Adrenergic Agonist
Action: Selects alpha-2 receptors, reduces aqueous humor formation and increases
uveoscleral outflow.
Use: Lower intraocular pressure with open-angle glaucoma or ocular hypertension.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Headache,
xerostomia and photophobia.
Dental Drug Interactions: Increases CNS depressant effects.
Brimonidine (Alphagan)
Antispasmodic Agent
 Urinary
Action: Inhibits action of acetylcholine on smooth muscle, no effect at skeletal muscle
or autonomic ganglia. Increases bladder capacity, decreases uninhibited bladder
contractions.
Use: Treat neurogenic bladder (problems with urgency, frequency, urge incontinence)
and uninhibited bladder.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Significant dry
mouth, headache, and fever.
Dental Drug Interactions: Increased anticholinergic effect with antihistamines and
anticholinergics. Additive sedation with CNS depressants.
Oxybutynin (Ditropan)
46
Antispasmodic Agent
 Urinary (continued)
Flavoxate (Urispas) Also treat dysuria, nocturia and suprapubic pain.
Dry
throat, blood dyscrasias.
Anticholinergic
Action: Completely blocks the action of acetylcholine at postganglionic parasympathetic
receptor sites.
Use: Treat peptic ulcer disease, irritable bowel syndrome, pancreatitis, duodenography,
urinary incontinence, ureter and urinary bladder spasm, induce dry field in oral cavity.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Dry mouth, absence
of taste, headache, dysphagia, photophobia and fever. Avoid in pregnancy, ok with
lactation.
Medical Considerations: >10%; constipation, decreased sweating.
1-10%; dysphagia.
Medical Considerations: Other adverse reactions; insomnia, dizziness, drowsiness,
anxiety, weakness, hallucinations, palpitations, tachycardia, paralytic ileus, heartburn,
nausea, vomiting, hesitancy, retention, impotence, blurred vision, mydriasis,
cycloplegia, increased ocular tension, urticaria, rash, pruritis, and allergic reactions.
Contraindications: Narrow angle glaucoma, ulcerative colitis, toxic megacolon,
obstructive disease of GI or urinary tract, myasthenia gravis.
Precautions: Hyperthyroid, hepatic, cardiac, endocrine or renal disease, hypertension,
GI disease, hiatal hernia and prostatic hypertrophy.
Dental Drug Interactions: Increases anticholinergic effects other anticholinergic drugs,
narcotics. Constipation, urinary retention with opioid analgesics.
Dental Drug Interactions: Decreased absorption of ketoconazole. Corticosteroids
increase intraocular pressure. Increased sedation with CNS depressants.
Medical Drug Interactions: Increased anticholinergic effect with antiarrhythmic agents,
antihistamines, phenothiazines, TCAs, beta-blockers. Decreased absorption with
antacids.
Propantheline (Pro-Banthine)
 Tolterodine (Detrol)
Action: Muscurinic receptor antagonist more specific for urinary bladder than salivary
glands.
Use: Treat overactive bladder with symptoms of urinary frequency, urgency or urge
incontinence.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Dry mouth, headache,
paresthesia, pharyngitis, sinusitis and arthralgia.
Dental Drug Interactions: None
47
Urinary Analgesic
Action: An azo dye, which exerts a local anesthetic effect on the urinary tract.
Use: Symptomatic relief of urinary burning, itching, frequency and urgency associated
with urinary tract infection or following urology procedures.
Dental Considerations: Local anesthetic with vasoconstrictor ok. Headache and blood
dyscrasias.
Dental Drug Interactions: None
Phenazopyridine (Pyridium)
Anti-Androgen
 Finasteride (Proscar, Propecia)
Action: Inhibits conversion of testosterone to dihydrotesterone. Does not effect fertility,
muscle strength, potency and libido. Works in liver skin and scalp.
Use: Proscar for symptomatic benign prostatic hyperplasia, after radical prostatectomy
for prostatic carcinoma. Propecia for treatment of male pattern baldness ages 18-41.
Dental Considerations: Local anesthesia with vasoconstrictor ok.
Dental Drug Interactions: Opiods and anticholinergics enhance urinary retention, use
alternative analgesics, NSAIDs.
 Flutamide (Eulexin)
Action: Nonsteroidal antiandrogen, which inhibits androgen uptake or androgen binding
at target tissues.
Use: In combination with LHRH agonist (Leuprolide) and radiation for metastatic
prostatic carcinoma.
Dental Considerations: Local anesthesia with vasoconstrictor ok.
Dental Drug Interactions: If urinary retention present avoid anticholinergics.
Alpha Adrenergic Blocking Agent
 Tamsulosin (Flomax)
Action: Antagonist for alpha adrenoreceptors in the prostate. Causes relaxation of
smooth muscle in prostate and bladder neck resulting in improvement in urine flow.
Use: Treat signs and symptoms of benign prostatic hyperplasia.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Tooth disorders,
headache, orthostatic hypotension, pharyngitis.
Dental Drug Interactions: Opiods and anticholinergics may enhance urinary retention,
use NSAIDs.
48
Skeletal Muscle Relaxant
 Baclofen (Lioresal)
Action: Inhibits transmission of synaptic reflexes at spinal cord level, causes some CNS
depression, results in relief of muscle spasticity.
Use: Skeletal muscle spasticity associated with multiple sclerosis and spinal cord injury.
Used intrathecal for cerebral spasticity. Also to treat trigeminal neuralgia, intractable
pain, intractable hiccups and bladder spasticity.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Headache, dry mouth,
taste disorder, tinnitus and paresthesia.
Dental Drug Interactions: Increased CNS depression alcohol, opiates, benzodiazepines
and all CNS depressants.
 Carisoprodol (Soma)
Action: Unclear acts in CNS and produces sedation.
Use: Treat muscle spasm associated with any skeletal muscle including TMJ.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Glossitis, swelling of
lips, headache, postural hypotension, fever and facial flushing. Avoid pregnancy, no
data on lactation.
Medical Considerations: >10%; drowsiness 1-10%; dizziness, lightheadedness
Medical Considerations: Other adverse reactions; weakness, tremor, depression,
insomnia, ataxia, irritability, tachycardia, nausea, vomiting, hiccups, epigastric
discomfort, diplopia, temporary visual loss, rash and pruritis.
Contraindication: Intermittent porphyria. Caution with renal or hepatic dysfunction.
Dental Drug Interactions: Increased CNS depression all CNS depressants.
Medical Drug Interactions: Increased CNS depression with phenothiazines and MAO
inhibitors.
 Chlorzoxazone (Parafon Forte)
Action: Depresses synaptic reflexes at spinal cord and subcortical levels.
Use: Treat muscle spasms of acute TMJ and acute painful musculoskeletal conditions. e
Dental Considerations: Local anesthesia with vasoconstrictor ok. Facial flushing, blood
dyscrasias and headache. Avoid pregnancy, no data with lactation.
Medical Considerations: >10%; drowsiness 1-10%; tachycardia, chest tightness,
syncope, depression, dizziness, lightheadedness, headache, angioedema,
Medical Considerations: paradoxical stimulation, vomiting, stomach cramps, trembling,
burning of eyes, dyspnea, hiccups and allergic fever.
Medical Considerations: Other possible reactions; insomnia, malaise, nausea, vomiting,
anorexia, diarrhea, constipation and urine discoloration, hepatotoxicity, jaundice, rash,
pruritis, petechiae, ecchymosis and anaphylaxis.
Drug Interactions: Increased CNS depression with alcohol, narcotics, barbiturates,
sedatives, hypnotics.
Contraindications: Hepatic dysfunction. Use with caution with lactation. Pregnancy
Category C.
49
 Cyclobenzaprine (Flexeril)
Action: Central acting skeletal muscle relaxant, related to tricyclic antidepressants.
Use: Treat muscle spasm associated with acute painful musculoskeletal conditions
including TMJ, tetanus.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Dry mouth, headache,
swelling of face and lips, facial flushing, paresthesia, postural hypotension and fever.
Pregnancy category B, no data on lactation.
Medical Considerations: >10%; drowsiness, dizziness, lightheadedness.
1-10%; syncope, bloated feeling, speaking problems, muscle weakness, blurred vision.
Other adverse reactions; tremor, depression, insomnia, confusion, tachycardia,
arrhythmias, vomiting, hiccups,
urinary retention, frequency, change in libido, diplopia, temporary loss of vision, rash,
pruritis and sweating.
Contraindications: Don’t use within 14 days of taking MAO inhibitors. Don’t give if
hyperthyroid, CHF, arrhythmias, immediately post MI, child <12 yrs. Use with
caution if urinary hesitancy or angle-closure glaucoma.
Drug Interactions: Increased CNS depression with alcohol, narcotics, barbiturates,
sedatives, hypnotics. Increased effects of anticholinergics.
Increased toxicity with TCAs. Increased effect of direct acting sympathomimetics
(epinephrine and levonordefrin).
 Orphenadrine (Norflex)
Action: Acts central to depress synaptic pathways. Has atropine like effects as well as
euphorgenic and analgesic properties.
Use: Treat muscle spasm associated with acute painful musculoskeletal conditions,
tetanus, TMJ.
Dental Considerations: Local anesthesia with vasoconstrictor OK. Dry mouth, facial
flushing, headache and blood dyscrasias. Avoid pregnancy, caution lactation.
Medical Considerations: >10%; drowsiness, dizziness, blurred vision.
1-10%; tachycardia, syncope, skin rash, vomiting and constipation.
Medical Considerations: 1-10%; decreased urination, weakness, nystagmus, increased
intraocular pressure and nasal congestion.
Medical Considerations: Other possible reactions; hallucinations and blood dyscrasias.
Contraindications: Hypersensitivity, narrow-angle glaucoma, GI obstruction,
myasthenia gravis, stenosing peptic ulcer, bladder neck obstruction and cardiospasm.
Dental Drug Interactions: Increased CNS depression with CNS depressants. Increased
anticholinergic effect with anticholinergics.
 Metaxalone (Skelaxin)
Action: Acts in central nervous system to cause skeletal muscle relaxation.
Use: Relief discomfort from acute, painful musculoskeletal conditions.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Headache and
blood dyscrasias.
Dental Drug Interactions: Increases action of CNS depressants.
50
Anti-Neoplastic Agent
 Quinine (Legatrin, Quinaglute)
Action: Disrupts malaria parasites replication and transcription, affects calcium
distribution within muscle fibers, decreases excitability of motor end plate region.
Use: Treatment of malaria and nocturnal leg cramps.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Lichenoid drug
reaction, headache, fever, blood dyscrasias, tinnitus, photophobia, facial edema
Dental Drug Interactions: Increases effect of coumadin.
 Tizanidine (Zanaflex)
Action: An alpha-2 adrenergic agonist, decreases excitatory input to alpha motor
neurons, also a central acting muscle relaxant and acts on the spinal cord.
Use: Intermittent management of increased muscle tone associated with spasticity due to
multiple sclerosis and spinal cord injury.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Dry mouth,
orthostatic hypotension, candidiasis.
Dental Drug Interactions: Additive sedation with other CNS sedatives.
Iron Salt
Ferrous Sulfate (Feosol, Feratab)
Action: Replaces iron found in hemoglobin, myoglobin and other enzymes. Needed for
red blood cell development, energy and oxygen transport.
Use: Prevention and treatment of iron deficient anemia, prophylaxis for iron deficiency
in pregnancy.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Extrinsic stain on
teeth (liquid form).
Dental Drug Interactions: If take tetracycline at same time absorption of both drugs is
decreased.
Iron Salt +
Ferrous Sulfate, Ascorbic Acid, Vitamin B-Complex and Folic
Acid (Iberet-Folic-500)
Only difference from iron salt alone is to prevent concomitant folic acid deficiency where
there is an associated deficient intake or increased need for B complex vitamins.
RBC Formation Stimulant
Epoetin (Epogen)
Action: Induces erythropoiesis by stimulating division and differentiation of erythroid
progenitor cells. Also induces release of reticulocytes from the bone marrow into the
blood stream where they mature to erythrocytes.
Use: Anemia associated with the following; end stage renal disease, AZT therapy for
AIDs, chemotherapy for cancer and prematurity.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Headache and
arthralgias.
Dental Drug Interactions: None
51
Anti-Neoplastic Agent
Hydroxyurea
Action: Inhibits DNA synthesis, no effect on synthesis of protein or RNA.
Use: Treat chronic myelocytic leukemia, melanoma, ovarian carcinoma, head and neck
cancer, adjunct in management of sickle cell anemia.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Stomatitis, erythema
of face, headache and significant blood dyscrasias. If surgical procedure make sure
WBCs adequate to prevent infection, platelets adequate for hemostasis, RBCs adequate
for oxygen if sedation or GA.
Dental Drug Interactions: Hepatotoxicity with alcohol and hepatotoxic drugs.
Methotrexate
Action: Inhibits enzyme that reduces folic acid, which is needed for nucleic acid
synthesis in all cells.
Use: Treat trophoblastic neoplasms, leukemias, psoriasis, rheumatoid arthritis and
hydatidiform mole. Carcinomas of the breast, head, lung, esophagus, stomach, and
testes. Osteosarcomas and sarcomas. Gestational choriocarcinoma.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Commonly causes
oral discomfort secondary to ulcerative stomatitis. Gingivitis, glossitis and pharyngitis.
Severe headache, cranial nerve palsy, rash, photosensitivity, chills, fever, arthralgia and
blood dyscrasias.
Dental Drug Interactions: Corticosteroids (except dexamethasone) and NSAIDs
decrease effect of methotrexate. Toxicity increased by salicylates, alcohol and
penicillin.
Dental Drug Interactions: Possible fatal reactions with NSAIDs and high dose IV
methotrexate.
Tamoxifen (Nolvadex)
Action: An antiestrogen hormone, binds to estrogen receptors on tumors and other tissue
targets results in decreased DNA synthesis and inhibits estrogen effects.
Use: Palliative or adjunctive treatment of advanced breast cancer. Treatment of
mastalgia, gynecomastia, male breast cancer and pancreatic carcinoma.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Blood dyscrasias and
headache.
Dental Drug Interactions: None
Mercaptopurine (Purinethol)
Action: Purine antagonist which inhibits DNA and RNA synthesis.
Use: Treatment of acute leukemias (ALL, CML)
Dental Considerations: Local anesthesia with vasoconstrictor ok. Drug fever,
stomatitis, blood dyscrasias and glossitis.
Dental Drug Interactions: None
52
Anti-Neoplastic Agent
Paclitaxel (Taxol)
Action: Inhibits microtubule network reorganization essential for cell division.
Use: Treat metastatic ovarian carcinoma, metastatic breast cancer, lung cancer, AIDs
related Kaposi’s sarcoma
Dental Considerations: Local anesthesia with vasoconstrictor ok. Mucositis, blood
dyscrasias, myalgia, arthralgia, fever.
Dental Drug Interactions: Increased activity with ketoconazole.
Imatinib (Gleevec)
Action: A protein tyrosine kinase inhibitor, inhibiting certain leukemic line cell growth.
Use: Treatment of chronic myeloid leukemia (CML).
Dental Considerations: Local anesthesia with vasoconstrictor ok. Headache, TMJarthralgia, TMJ-myalgia, pharyngitis.
Dental Drug Interactions: Increases Imatinib concentration; itraconazole,
ketoconazole, erythromycin, clarithromycin. Decadron decreases Imatinib
concentration.
Immune Globulin
Action: Provides passive immunity by increasing the antibody titer and antigen-antibody
reaction potential. Interferes with receptors on the reticuloendothelial system for
autoimmune cytopenias and ITP, possibly contains antiviral antibodies.
Use: I.M. for exposure to hepatitis A, measles, varicella and possibly rubella.
Prophylactic for travelers to certain areas. I.V. to treat immunodeficiency syndrome,
idiopathic thrombocytopenia and chronic lymphocytic leukemia. Used to prevent or
modify acute bacterial or viral infections in immunodepressed states; autoimmune
neutropenia, bone marrow transplantation, Kawasaki disease, Gullian-Barre syndrome,
demyelinating polyneuropathies.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Facial flushing,
chills, fever, myalgia and headache.
Dental Drug Interactions: None
Interferon
Action: Alters the expression and response to surface antigens and can enhance immune
cell activities. Mechanism in treatment of multiple sclerosis is unknown.
Use: Treatment of relapsing forms of multiple sclerosis. Slows accumulation of physical
disability and decreases frequency of clinical exacerbations. Given by intramuscular
injection.
Dental Considerations: Local anesthesia with vasoconstriction ok. Headache and blood
dyscrasias.
Dental Drug Interactions: None.
Interferon Beta-1a (Avonex)
53
Immunosuppressant Agent
Cyclosporine (Sandimmune)
Action: Inhibits production and release of interleukin II, which activates
resting T lymphocytes.
Use: Immunosuppressant used for kidney, liver, heart and bone marrow
transplants.
Dental Considerations: Local anesthesia with vasoconstrictor ok.
Gingival hyperplasia, headache, myalgia, paresthesia, sinusitis.
Dental Drug Interactions: Azole antifungals increase effects.
Azathioprine (Imuran)
Action: Antagonizes purine metabolism and may inhibit synthesis of DNA,
RNA, and proteins. May also interfere with cellular metabolism and
Inhibit mitosis.
Use: Adjunct with other agents in prevention of rejection of solid organ
transplants. Used in severe unresponsive rheumatoid arthritis.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Fever,
blood dyscrasias, aphthous stomatitis, arthralgia, myalgia.
Dental Drug Interactions: None.
Mycophenolate (CellCept)
Action: Inhibits purine synthesis of human lymphocytes and proliferation
of human lymphocytes.
Use: Prevent organ rejection for allogenic renal transplants.
Dental Considerations: Local anesthesia with vasoconstrictor ok.
Headache, fever, oral monoliasis, blood dyscrasias and pharyngitis.
Dental Drug Interactions: None.
Tacrolimus (Prograf)
Action: Suppresses humoral immunity, inhibits T cell activation, very
potent.
Use: Immunosuppressant drug used in liver, kidney, heart, lung or small
bowel transplant recipients.
Dental Considerations: Local anesthesia with vasoconstrictor ok.
Headache, fever, blood dyscrasias and paresthesias.
Dental Drug Interactions: Don’t use with nephrotoxic antibiotics,
increases nephrotoxicity. Not good to use with macrolide antibiotics and
azole antifungals. Methylprednisolone is synergistic with it. Seldane
and Hismanal cause cardiac arrhythmias with it.
54
Immunosuppressant Agent
Leflunomide (Arava)
Action: Inhibits pyrimidine synthesis, anti-inflammatory and antiproliferative effects.
Use: Active rheumatoid arthritis, reduce signs and symptoms and retards structural
damage.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Dry mouth, taste
disturbance, oral ulcers, candidiasis, paresthesias, sinusitis, arthralgia, headache, pain,
fever, stomatitis, gingivitis, enlarged salivary gland, tooth disorder, myalgia, blood
dyscrasias.
Dental Drug Interactions: May increase levels of NSAIDs.
Anorexiant
Phentermine (Fastin, Adipex)
Action: An amphetamine, stimulates hypothalamus which results in decreased appetite.
Use: Short term adjunct to exogenous obesity.
Dental Considerations: Local anesthetic with vasoconstrictor may result in enhanced
sympathomimetic response resulting in hypertension and cardiotoxicity.
Dental Considerations: Dry mouth, unpleasant taste, blood dyscrasias and myalgias.
Dental Drug Interactions: Counteract sedative effects of antihistamines. Potentiates
analgesic effects of meperidine.
Fenfluramine (Pondimin) Removed from market in 1997
Dexfenfluramine (Redux)
Any patients with history of taking these drugs are in danger of cardiac valvulopathy.
They need medical exam and also echocardiograph if undergoing invasive procedure.
Removed from market in 1997.
Dexfenfluramine & Fenfluramine (Redux Fen)
Fenfluramine & Phentermine (Fen Phen)
If emergency give AHA antibiotic prophylaxis. Fenfluramine was combined with
Phentermine to form the popular Fen Phen combination. There are no valvular
problems with phenteramine. Your history should ask if these meds ever were taken
by patient.
Sibutramine (Meridia)
Action: Mixed reuptake inhibitor, CNS, of norepinephrine, and to lesser extent serotonin
and dopamine.
Use: Management of obesity.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Headache, dry
mouth, taste alteration, TMJ-arthralgia, pharyngitis, sinusitis.
Dental Drug Interactions: Erythromycin, ketoconazole, itraconazole, increase
sibutramine levels, serotonin syndrome with demerol, tramadole.
55
Anti-Alcoholic Agent
Disulfiram (Antabuse)
Action: Blocks oxidation of alcohol at the acetaldehyde stage. Increase in serum
acetaldehyde results in flushing, nausea, thirst, palpitations, chest pain, vertigo and
hypotension. Disulfiram-alcohol reaction can also include throbbing, respiratory
difficulty, vomiting, sweating, dyspnea, hyperventilation, tachycardia, confusion, CV
collapse, MI, CHF, convulsions and death.
Use: Management of chronic alcoholism.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Headache and
metallic or garlic-like aftertaste.
Dental Drug Interactions: Increased CNS depression with long acting benzodiazepines.
Alcohol reaction. Do not use with metronidazole, causes psychosis.
Smoking Deterrent
Nicotine (Nicoderm, Nicorette)
Action: Potent autonomic ganglionic and central nervous system stimulant. Larger
doses result in biphasic effect, stimulation followed by blockage of transmission of
ganglia and adrenal medulla. CNS stimulation characterized by tremors, respiratory
excitation. Larger doses may cause convulsions and respiratory failure.
Use: Aid to smoking cessation with behavior modification.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Burning oral mucosa
and unpleasant taste.
Dental Considerations: Increased salivation, dry mouth (rare), sore throat, numbness,
tinnitus, arthralgia and headache and jaw muscle ache.
Medical Considerations: Tachycardia, atrial fibrillation, nausea, vomiting, indigestion,
belching, increased appetite, hiccups, insomnia, depression, euphoria, dizziness,
vertigo, nervousness, dysmenorrhea, diarrhea, dyspepsia, constipation, abdominal pain,
vomiting, eructation, myalgia, hoarseness, cough, sneezing, wheezing, erythema,
itching and pruritis.
Contraindications: Pregnancy or nursing, life-threatening arrhythmias, immediate post
myocardial infarction period, severe or unstable angina pectoris.
Precautions: Esophagitis, peptic ulcer, CAD, hypertension, pheochromocytoma,
hyperthyroidism, diabetes, renal and hepatic dysfunction, and skin disease.
Dental Drug Interactions: Increased blood levels at cessation of smoking of
propoxyphene. Decreases effect of caffeine and pentazocine.
Medical Drug Interactions: Decreases effect of Imipramine, Oxazepam, Propranolol,
theophylline, Glutethimide and lithium patch. Increases effects of furosemide, insulin
and circulating cortisol and catecholamines.
56
Anti-Malarial Agent
Hydroxychloroquine (Plaquenil)
Action: Inhibits parasite replications, transcription of DNA to RNA by forming
complexes with DNA of parasite. Also interferes with digestive vacuole function in
malarial parasite. Inhibits PMN locomotion, chemotaxis of eosinophils and impairs
complement dependent antigen-antibody reactions.
Use: Suppress and treat acute attacks of malaria. Treat systemic lupus erythematosus
and rheumatoid arthritis.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Discoloration of oral
mucosa and lichenoid lesions, headache, blood dyscrasias, tinnitus and photophobia.
Dental Drug Interactions: Hepatotoxicity with alcohol and hepatotoxic drugs.
Chelating Agent
Penicillamine (Cuprimine, Depen)
Action: Chelates with lead, copper, mercury and other heavy metals to form stable,
soluble complexes that are excreted in urine, combines with cystine to form more
soluble compound to prevent cystine calculi, depresses circulating IgM rheumatoid
factor, depresses T-cell but not B-cell activity.
Use: Treat Wilson’s disease, cystinuria, adjunct in treatment of severe rheumatoid
arthritis, lead poisoning, primary biliary cirrhosis.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Fever, arthralgia,
edema of face, chills, sore throat, blood dyscrasias, white spots on lips or mouth,
tinnitus.
Dental Drug Interactions: None.
Multiple Sclerosis Agents
Giltiramer (Copaxone)
Action: Mixture of polymers of amino acids antigenically similar to myelin sheath of
nerves, interferes with T-lymphocytes specific for attacking myelin sheath.
Use: Treat multiple sclerosis, most effective with minimal disability.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Pain, TMJ-arthralgia,
fever, chills, headache, facial edema, lupus erythematosus, blood dyscrasias.
Dental Drug Interactions: None
Antibiotic
 Penicillin Derivative
Action: Inhibits bacterial cell wall synthesis resulting in cell wall lysis.
Use: Treat aerobic gram positive cocci and anaerobic infections. Including dental,
respiratory tract, otitis media, sinusitis, and urinary tract.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Candidiasis, glossitis,
stomatitis, black hairy tongue, dry mouth, altered taste and blood dyscrasias.
Medical Considerations: >10%; nausea, vomiting, diarrhea
1-10%; hypersensitivity reactions
57
Antibiotic
 Penicillin Derivative (continued)
Medical Considerations: Other adverse reactions; coma, depression, convulsions,
lethargy, hallucinations, anxiety, twitching, abdominal pain, colitis, anorexia, oliguria,
proteinuria, hematuria, vaginitis, monoliasis, glomerulonephritis, hyperkalemia,
hypokalemia and alkalosis.
Precautions: Severe renal impairment, seizure history and allergic to cephalosporins.
Can reduce effectiveness of oral contraceptives. Pregnancy category B, lactation ok.
Dental Drug Interactions: When used with tetracyclines, erythromycin and lincomycin
there is a decreased effectiveness. Acts synergistically with aminoglycosides.
Probenecid increases blood levels of penicillins.
Penicillin V Potassium (Pen Vee K, V-Cillin K, Veetids)
First choice for common orofacial infections. Not for endocarditis or orthopedic
prosthesis prophylaxis.
Amoxicillin (Amoxil, Biomox, Trimox)
First choice for endocarditis, prosthesis prophylaxis. Superinfections tend to develop
rash with infectious mononucleosis.
Ampicillin (Amcill, Polycillin)
Alternative for dental prophylaxis. Severe abdominal cramps. Increases effect of oral
anticoagulants. Can develop nonallergic rash, especially if viral and Salmonella
infections, lymphocytic leukemia, hyperuricemia or taking Allopurinol.
 Penicillin Derivative +
Amoxicillin and Clavulanate Potassium (Augmentin)
Clavulanate inactivates beta lactamase, can use with beta-lactamase staphylococci and
bacteroides. Rash with Allopurinol. Treat otitis media, sinusitis, lower respiratory
tract, urinary tract, skin infections and gonorrhea. Increased diarrhea. Caution if
hepatic dysfunction.
Ampicillin and Sulbactam (Unasyn)
Sulbactam is a beta-lactamase inhibitor. Treat severe orofacial infections from
Staphylococci and Bacteroides.
Treat skin, intrabdominal and gynecological infections. Only given I.M. or I.V. May
follow with oral Augmentin.
Good against beta-lactamase producers S. aureus, H. influenzae, E. coli, Klebsiella,
Acinetobacter, Enterobacter and anaerobes.
58
Antibiotic
 Macrolide
Action: Inhibits RNA dependent protein synthesis by binding 50S ribosomal subunit.
Use: Alternative to penicillin for orofacial infections. Also treat M. pneumoniae,
Legionella pneumophilia, diphtheria, pertussis, chancroid, Chlamydia and
Campylobacter gastroenteritis.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Candidiasis and
tinnitus. Pregnancy category B, lactation ok.
Medical Considerations: >10%; abdominal pain, cramping, nausea and vomiting.
1-10%; cholestatic jaundice and hypersensitivity reactions.
Medical Considerations: Other adverse reactions; heartburn, pruritis ani,
psuedomembranous colitis, vaginitis, monoliasis and hearing loss.
Contraindications: Hepatic disease.
Dental Drug Interactions: Decreases action of clindamycin, penicillins, lincomycin and
oral contraceptives. Increases effects of oral anticoagulants and benzodiazepines.
Medical Drug Interactions: Increases effects of alfentanil, carbamazepine, theophylline,
felodipine, triazolam and ergotamine. Contraindicated with pimozole, terfenadine,
astemizole, lovastin and cisapride.
Erythromycin (E.E.S., Ilosone, E-Mycin, Ery-Tab, Erythrocin)
Patients may be unable to tolerate due to abdominal pain. Used with neomycin to
decontaminate bowel. Used to improve gastric emptying.
Clarithromycin (Biaxin)
Alternative for dental prophylaxis, endocarditis only. Effective against most respiratory
pathogens including H. influenzae, C. pneumoniae and M. avium.
Headache. Used in combination with Omeprazole for H. pylori duodenal ulcer.
Pregnancy category C, lactation ok. Also use with caution with renal disease.
Decreases effects of anticholinergics, rifabutin, rifampin and zidovudine. Increases
effects of cyclosporine and digoxin.
Azithromycin (Zithromax)
Alternative for orofacial infections and dental endocarditis prophylaxis, good against
most respiratory pathogens and gonorrhea, chancroid. Headache.
 Lincomycin derivative
Clindamyacin (Cleocin)
Action: Reversibly binds to 50’s ribosomal subunits to prevent peptide formation and
inhibit bacterial protein synthesis. Can be bacteriostatic or bactericidal.
Use: Treat orofacial infections. Alternative for endocarditis and prosthetic
joint prosthesis prophylaxis. Treat aerobic and anaerobic streptococci (not
enterococci), most staphylococci, Bacteroides, Actinomyces. Alternative for
toxoplasmosis. Topically for severe acne, vaginally for Gardnerella vaginalis.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Stevens Johnson
syndrome, blood dyscrasias, candidiasis.
Medical Considerations: >10%; Psuedomembranous colitis, GI upset. 1 to 10%;
hypotension, urticaria, rashes, polyarthritis, fungal overgrowth.
59
Antibiotic
 Lincomycin derivative
Clindamyacin (Cleocin) (Continued)
Contraindications: Ulcerative colitis, enteritis, pregnancy category B, lactation.
Dental Drug Interactions: Decreases activity of erythromycin, increases activity of
of nondepolarizing muscle relaxants and hydrocarbon inhalation anesthetics.
 Cephalosporin (First Generation)
Action: Inhibits cell wall synthesis resulting in cell lysis. No problem with betalactamase.
Use: Alternative to dental prophylaxis and orofacial infections (aerobic gram positive
and anaerobic bacteria). Also treat group A beta hemolytic Streptococcus, Klebsiella
pneumoniae, E. coli, Proteus mirabilis and Shigella. Predominantly used for lower
respiratory tract, urinary tract, skin and soft tissue, and bone and joint infections.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Candidiasis, glossitis,
headache, paresthesia, fever, and chills. Pregnancy category B, lactation ok. Blood
dyscrasias and psuedomembranous colitis. Prolong use may result in superinfection.
Medical Considerations: 1-10%; diarrhea. Other adverse effects; dizziness, weakness,
nausea, vomiting, anorexia, abdominal pain, GI bleeding and increased AST/ALT,
bilirubin, increased LDH, alk phosphatase, BUN, dyspnea, nephrotoxicity, renal
failure, proteinuria, vaginitis, pruritis, rash, urticaria and dermatitis.
Dental Drug Interactions: Decreased bactericidal effects with tetracyclines and
erythromycin. May reduce effectiveness of oral contraceptives.
Medical Drug Interactions: Probenecid decreases elimination.
Precautions: Low incidence of cross-hypersensitivity with penicillin. Reduce dose with
severe renal disease.
Cephalexin (Keflex, Keftab) #27 & 54 in 97’, alternative for dental
endocarditis and orthopedic prosthesis prophylaxis.
Cefadroxil (Duricef) alternative for dental endocarditis prophylaxis.
 Cephalosporin (Second Generation)
Actions, drug interactions, precautions same as first generation. For use has broader
spectrum of activity.
Cefprozil (Cefzil)
Cefuroxime (Ceftin)
Cefaclor (Ceclor)
Loracarbef (Lorabid)
Cefpodoxime (Vantin)
60
Antibiotic
 Cephalosporin (Third Generation)
Cefixime (Suprax)
Outpatient therapy for serious soft tissue or skeletal infections, single dose treatment of
uncomplicated N. gonorrhea.
Cefdinir (Omnicef)
 Tetracycline Derivative
Action: Inhibits protein synthesis by binding to 30s, possibly 50s ribosomes. May also
alter cytoplasmic membrane. Bacteriostatic.
Use: Treat periodontitis due to Actinobacillus actinomycetemcomitans. Adjunctive
therapy for recurrent aphthous ulcers. Also sinusitis.
Treat susceptible infections due to gram positive and negative organisms. Also
unusual organisms; Mycoplama, Chlamydia and Rickettsia.
Also for acne, ophthalmic infections, exacerbations of chronic bronchitis, gonorrhea
and syphilis (if allergic to penicillin). In combination with other meds for H. pylori
ulcers.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Candidiasis, tongue
discoloration with hypertrophy of papilla, gingival bleeding, stomatitis, lichenoid drug
reaction and erythema multiforme. Fever, headache, paresthesia, blood dyscrasias and
dysphagia. Don’t use if pregnant, children < 8yrs. Lactation ok.
Medical Considerations: <1%; pericarditis, nausea, vomiting, abdominal pain, diarrhea,
anorexia, hepatotoxicity, enterocolitis, flatulence and abdominal cramps, epigastric
burning, increased BUN, rash, urticaria, photosensitivity, increased pigmentation,
exfoliative dermatitis, angioedema and pruritis.
Dental Drug Interactions: Decreases effect of penicillin, cephalosporins, oral
contraceptives. Increases oral anticoagulant effect.
Medical Drug Interactions: Dairy products, calcium, magnesium or aluminum
containing antacids, iron, zinc, cimetidine reduces absorption.
Outdated drug can cause nephropathy. If given with Methoxyflurane anesthesia can
cause fatal nephrotoxicity.
Precautions: Don’t use in pregnancy or children under age 8 as causes enamel
hypoplasia and discoloration of permanent teeth. Use with caution if renal or hepatic
impairment.
Tetracycline (Achromycin, Sumycin, Tetracyn)
Minocycline (Minocin) ANUG
61
Antibiotic
 Tetracycline Derivative (continued)
Doxycycline (Vibramycin) Used for ANUG, alternative to mefloquine for
malaria prophylaxis and sclerosing agent for pleural effusions. Decreases effect of
barbiturates, carbamazepine and hydantoins.
Tetracycline Periodontal Fibers (Actisite) Gingival inflammation, pain
in mouth, glossitis, candidiasis, staining of tongue. No drug interactions reported, but
birth control pill warning.
Chlorhexidine (Peridex, PerioGard, Hibiclens)
Action: Binds to bacterial cell wall, at low concentration is bacteriostatic causing
leakage of potassium and phosphorous. At high concentration bactericidal, precipitates
cytoplasmic contents.
Use: Dental rinse active against gram positive and negative organisms, facultative
anaerobes, aerobes and yeast.
Treat periodontal disease, dentin hypersensitivity, high caries index, xerostomia,
nonviral oral ulcerations and prophylaxis.
Skin cleanser for surgical scrub, germicidal hand rinse, cleanser for skin wounds.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Staining of teeth,
tongue and restorations, nasal congestion and dyspnea. Increased calculus formation,
taste alterations, mucosal desquamation and irritation, transient parotitis.
Dental Drug Interactions: None
Precautions: Pregnancy Category B, no breast-feeding data.
 Quinolone
Action: Bactericidal inhibits DNA gyrase, which is required for DNA replication,
transcription, repair, recombination, transposition and maintenance of helical structure.
Use: Treat skin, lower respiratory tract infections, UTI, sexually transmitted disease and
bacterial conjunctivitis (topical).
Dental Considerations: Local anesthesia with vasoconstrictor ok. Headache, dry mouth,
candidiasis, photophobia, paresthesia and tinnitus.
Dental Drug Interactions: Increases caffeine and oral anticoagulant levels. Decreased
absorption with bicarbonates.
Ofloxacin (Floxin)
Ciprofloxacin (Cipro) Typhoid fever, used alone or with metronidazole for
periodontal disease, infectious diarrhea
Levofloxacin (Levaquin)
Gatifloxacin (Tequin)
62
Antibiotic
 Nitrofurantoin (Macrodantin, Macrobid)
.
Action: Inhibits several bacterial enzyme systems interfering with metabolism and
possibly cell wall synthesis.
Use: UTI, good against gram positive and some gram negatives. Pseudomonas, Serratia
and Proteus are resistant.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Angioedema, brown
discoloration of saliva, tooth staining, chills, fever, headache, sore throat, paresthesia,
anemia, arthralgia.
Dental Drug Interactions: Increases effects of anticholinergics.
 Trimethoprim and Sulfmethoxazole (Bactrim, Septra,
Sulfatrim)
Action: Both interfere with bacterial folic acid synthesis in a different manner.
Use: Treat UTI, acute otitis media in children. Prophylaxis and treatment of
Pneumocystitis carinii pneumonitis (AIDS), shigellosis, typhoid fever, Nocardis
asteroides infections.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Stevens-Johnson
syndrome, Erythema multiforme, blood dyscrasias, fever, stomatitis and
psuedomembranous colitis.
Dental Drug Interactions: Increases effects of oral anticoagulants.
 Topical
Mupirocin (Bactroban)
Action: Inhibits bacterial protein and RNA synthesis.
Use: Impetigo caused by S. aureus, B-hemolytic Streptococcus, S. pyogenes. Nasal
membrane infection from S. aureus.
Dental Considerations: Local anesthesia with vasoconstrictor ok.
Dental Drug Interactions: None
Antibiotic +
 Topical
Neomycin, Polymyxin B, and Hydrocortisone (Cortisporin
Ophthalmic Suspension)
Action: Neomycin interferes with bacterial protein synthesis. Hydrocortisone is antiinflammatory.
Polymyxin alters cell wall permeability and damages bacterial cytoplasmic
membrane permitting leakage of intracellular constituents.
Use: Steroid responsive inflammatory condition where bacterial infection or risk exists.
Ophthalmic conditions.
Dental Considerations: Local anesthesia with vasoconstrictor ok.
Dental Drug Interactions: None
63
Antibiotic +
 Topical
Tobramycin and **Dexamethasone (TobraDex)
Action: *Interferes with bacterial protein synthesis by binding to 30S and 50S ribosomal
subunits. *Results in defective bacterial cell membrane. **Anti-inflammatory.
Use: Treat external ocular infection caused by susceptible gram-negative bacteria and
steroid responsive inflammatory conditions.
Dental Considerations: Local anesthesia with vasoconstrictor ok.
Dental Drug Interactions: None
Antifungal Agent
Fluconazole (Diflucan)
Action: Inhibits ergosterol biosynthesis causing direct damage to fungal cell membrane
and inhibition of cell membrane synthesis.
Use: Oropharyngeal candidiasis, chronic mucocutaneous candidiasis, urinary candidiasis
and cryptococcal meningitis.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Headache and
Stevens-Johnson syndrome. Pregnancy no, lactation ok.
Medical Considerations: 1-10%; skin rash, nausea, vomiting, abdominal pain and
diarrhea.
Medical Considerations: Other adverse reactions; cramping, flatus, increased
AST/ALT, exfoliative skin disorders, abnormal liver function.
Dental Drug Interactions: Increases warfarin and benzodiazepine activity.
Medical Drug Interactions: Increases activity of cyclosporine, oral hypoglycemics,
theophylline and phenytoin. Rifampin decreases fluconazole activity. Risk
arrhythmias with some antihistamines.
Precautions: Use with caution if renal or hepatic impairment.
Nystatin (Mycostatin)
Action: Binds to sterols in fungal cell membrane, changing cell wall permeability
allowing for leakage of cellular contents. Also interferes with fungal DNA replication.
Use: Candida species causing oral, vaginal and intestinal infections.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Stevens-Johnson
syndrome. Pregnancy risk factor B/C. Lactation ok.
Medical Considerations: 1-10%; nausea, vomiting, diarrhea and abdominal pain. Other
adverse reactions; rash, anorexia, cramps and urticaria.
Drug Interactions: None
64
Antifungal Agent
Clotrimazole (Mycelex Troche)
Action and Use: Same as nystatin.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Pregnancy risk factor
B, C for oral, lactation ok.
Medical Considerations: >10%; abnormal liver function tests.
1-10%; nausea, vomiting. Mild burning, irritation, stinging to skin or vaginal area.
Medical Drug Interactions: Increases activity of cyclosporines and sulfonylureas.
Antifungal Agent +
Betamethasone and Clotrimazole (Lotrisone)
Action: Anti-inflammatory plus antifungal.
Use: Topical treatment of various dermal fungal conditions.
Dental Considerations and Drug Interactions: Nothing major, same as individual
components.
Antiviral Agent
Acyclovir (Zovirax)
Action: Inhibits DNA synthesis and viral replication.
Use: Treatment of initial and prophylaxis of recurrent oral mucosal and cutaneous herpes
simplex (HSV-1 and HSV-2) infections.
Use: Treat herpes genitalis (HSV-1 and HSV-2), herpes zoster, varicella (chicken pox),
herpes simplex encephalitis and herpes zoster ophthalmicus.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Headache, glossitis
and blood dyscrasias. Don’t use if pregnant, lactation ok.
Medical Considerations: 1-10%; convulsions, tremors, dizziness, confusion, lethargy,
agitation, coma, rash, nausea, vomiting and elevated creatinine.
Medical Considerations: Other adverse reactions; hallucinations, diarrhea, increased
ALT/AST, abdominal pain, colitis, vaginitis, monoliasis, glomerulonephritis, acute
renal failure, changes in menses, oliguria, proteinuria, hematuria, urticaria and pruritis.
Dental Drug Interactions: None
Medical Drug Interactions: Increased CNS side effects with zidovudine (AIDS drug)
and probenecid.
Precautions: Hepatic and renal disease, electrolyte imbalance, dehydration.
 Protease Inhibitor
Action: Prevents cleavage of protein precursors essential for HIV infection
of new cells and viral replication.
Use: Treatment of HIV, especially advanced cases, as part of triple or
double therapy with other nucleoside and protease inhibitors.
Dental Considerations: Local anesthesia with vasoconstriction ok.
Circumoral paresthesia and headache.
Dental Drug Interaction: Risk cardiac arrhythmias with some antihistamines. Increases
concentration of benzodiazepines,
65
Antiviral Agent
 Protease Inhibitor f(continued)
meperidine, piroxicam and propoxyphene. Dexamethasone decreases
effects. Azole antifungals, ketoconazole, increases effects, can also be
cardiotoxic.
Ritonavir (Norvir)
Indinavir (Crixivan)
Saquinavir (Invirase) Stevens-Johnson syndrome, blood dyscrasias.
Nelfinavir (Viracept)
Amprenavir (Agenerase)
 Nucleoside Analog
Action: Inhibit HIV replication in both T cells and monocytes. Block viral
DNA synthesis.
Use: Treatment of advanced HIV infection.
Dental Considerations: Local anesthesia with vasoconstrictor ok.
Headache, blood dyscrasias.
Dental Drug Interactions: Decreases absorption of tetracyclines.
Decreases absorption of oral azole antifungals.
Didanosine (Videx)
 Thymine Analogue
Action: Interferes with HIV viral RNA dependent DNA polymerase resulting in
inhibition of viral replication.
Use: Management of Aids patients.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Severe
Headache and blood dyscrasias.
Dental Drug Interactions: Inhibit excretion of acetaminophen,
indomethacin, lorazepam and aspirin.
Zidovudine (Retrovir, AZT)
66
Antiviral Agent
 Lamivudine (Epivir, 3TC)
Action: Inhibits HIV reverse transcription via viral DNA chain termination and inhibits
RNA and DNA dependent DNA polymerase activities of reverse transcriptase.
Use: In combination with AZT and protease inhibitor for HIV where disease is
progressing, with AZT for HIV prophylaxis following needle sticks, treatment of
Hepatitis B.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Headache,
paresthesia, fever, chills, blood dyscrasias, myalgia and arthralgia.
Dental Drug Interactions: None.
Zidovudine and Lamivudine (Combivir, AZT + 3TC)
Stavudine (Zerit) Treat advanced HIV when problems with other agents
 Ganciclovir (Cytovene, Vitrasert)
Action: Inhibits binding of deoxyguanosine triphosphate to DNA polymerase
resulting in inhibition of viral DNA synthesis.
Use: CMV retinitis, pneumonia, colitis, and mulitorgan involvement with
Aids patients, marrow transplant recipients.
Dental Considerations: Local anesthesia with vasoconstrictor ok.
Headache, blood dyscrasias, fever and paresthesias.
Dental Drug Interactions: None.
 Etavirenz (Sustiva)
Action: A non-nucleoside reverse transcriptase inhibitor.
Use: Treat HIV-1 infections, hepatitis B and herpes viruses.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Headache, fever, dry
mouth, altered taste, TMJ-arthralgia, TMJ-myalgia, TMJ-tinnitus, blood dyscrasias,
paresthesia.
Dental Drug Interactions: Decreases clarithromycin and warfarin effects. Increases
effects of midazolam and triazolam effects.
Vitamin A Derivative
 Isotretinoin (Accutane)
Action: Reduces sebaceous gland size and reduces sebum production. Regulates cell
proliferation and differentiation.
Use: Severe recalcitrant cystic acne. Investigational for metastatic neuroblastoma and
leukemia in children unresponsive to normal medication.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Dry mouth, cheilitis,
inflammation of lips, gingival bleeding, headache, arthralgia, myalgia and
photophobia.
Dental Drug Interactions: Additive photosensitivity with tetracycline. Pseudotumor
cerebri with tetracyclines.
67
Vitamin A Derivative
 Tretinoin, Topical (Retin-A)
Action: Keratinocytes in sebaceous follicle become less adherent allowing easier
removal. Decreases microcomedone formation.
Use: Treatment of acne vulgaris, photodamaged skin, skin cancer and lichen planus.
Dental Considerations: Local anesthesia with vasoconstrictor ok.
Dental Drug Interactions: Increased photosensivity with tetracyclines. Increased
toxicity salicylic acid.
Vitamin D Derivative
 Calcitrol (Rocaltrol, Calcijex)
 Doxercalciferol (Hectorol)
Action: Promotes absorption of calcium in intestines and retention in kidneys, thus
increases calcium levels, decreases serum phosphatase levels, parathyroid levels,
decreases bone resorption, increases renal tubule phosphate resorption.
Use: Treat hypocalcemia due to chronic renal dialysis, reduce elevated parathyroid
hormone, treat psoriasis.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Headache, altered
taste, TMJ-myalgia, photophobia
Dental Drug Interactions: None.
Non-Narcotic Analgesic
 Non-Steroidal Anti-inflammatory Drugs (NSAIDs)
Action: Analgesic decreases prostaglandin formation. Prostaglandin allows bradykinin
to be perceived as painful. Anti-inflammatory, prostaglandin increases capillary blood
flow and permeability. There is decreased prostaglandin. Anti-pyretic, inhibits
prostaglandin synthesis by hypothalamus which reduces temperature.
 Salicylate NSAIDs
Use: Treat mild to moderate pain, fever, transient ischemic attacks, thromboembolic
disorders, rheumatoid arthritis, rheumatic fever, osteoarthritis, gout (high dose), and
treat and prophylaxis for myocardial infarction.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Increased oral
bleeding (chronic, high doses), headache, blood dyscrasias and tinnitus. If possible
avoid one week prior to surgery. Pregnancy and lactation, no.
Medical Considerations: >10%; nausea, vomiting, dyspepsia, epigastric discomfort,
heartburn. 1-10%; GI ulceration. 0.2% aspirin allergy; asthmatic syndrome, wheezing,
bronchiolar constriction.
Medical Considerations: Other adverse reactions; coma, convulsion, stimulation,
drowsiness, dizziness, confusion, flushing, hallucinations, rapid pulse, pulmonary
edema, hepatitis, diarrhea and anorexia, hyperpnea, hearing loss, rash, urticaria,
bruising, hypoglycemia, hyponatremia and hypokalemia.
68
Non-Narcotic Analgesic
 Salicylate NSAIDs (continued)
Dental Drug Interactions: Increased bleeding risk oral anticoagulants. May reduce
effect of other NSAIDs. Avoid corticosteroids and acetaminophen.
Medical Drug Interactions: Can cause toxicity of acetazolamide (CNS) and
methotrexate (hepatic). Increased GI bleeding and complaints alcohol. Increased risk
bleeding valproic acid, dipyridamole. Increased toxicity lithium and zidovudine.
Decreased effects of probenecid and sulfinpyrazone.
Contradictions: Don’t use if bleeding or platelet disorder, renal and hepatic
dysfunction, ulcer disease and allergic to tartazine dye. Children <16 with chickenpox
or flu symptoms (Reyes Syndrome). Use with caution in asthmatics.
Acetylsalicylic Acid (Aspirin, Anacin, Bayer, Bufferin, Ecotrin,
Empirin)
 Salicylate NSAIDs +
Orphenadrine, Aspirin and Caffeine (Norgesic, Norgesic Forte)
Orphenadrine is muscle relaxant Norflex, dry mouth. Treat skeletal muscle discomfort.
 Propionic acid derivative NSAIDs
Use: Mild to moderate pain, swelling, rheumatoid, gouty and osteoarthritis, primary
dysmenorrhea and vascular headache.
Dental & Medical Considerations: Same as salicylates plus dry mouth, stomatitis and
increased thirst.
Dental & Medical Drug Interactions: Same as salicylates. Nephrotoxic with
acetaminophen. Increased photosensitivity with tetracycline. Increased toxicity
diuretics. Not with methotrexate.
Ketoprofen (Orudis, Oruvail) Pregnancy B
Oxaprozin (Daypro) Pregnancy C, mainly arthritis treatment.
Erythema
multiforme, Stevens-Johnson syndrome.
Naproxen (Aleve, Anaprox, Naprosyn) Decreases effects of furosemide.
Pregnancy B (D 3rd trimester). Also treat fever.
Ibuprofen (Advil, Motrin, Midol, Nuprin, Rufen) Juvenile
rheumatoid arthritis, ankylosing spondylitis, acute migraine headache. Antiplatelet
effect only lasts as long as drug in blood. Pregnancy B (D in 3rd trimester).
 Acetic Acid derivative NSAIDs
Use: Mainly arthritis.
Dental & Medical Considerations: Same as other proprionics plus 1-10%; nervousness,
itching, fluid retention. <1%; hypertension, congestive heart failure, arrhythmias,
Erythema multiforme and toxic epidermal necrolysis.
Dental & Medical Considerations: <1%; Stevens-Johnson syndrome, angioedema,
hyperkalemia, hot flashes, polydipsia, cystitis, hepatitis, peripheral neuropathy,
69
Non-Narcotic Analgesic
 Acetic Acid derivative NSAIDs (Continued)
depression, corneal opacities, visual disturbances dry eyes, polyuria, renal failure,
dyspnea, allergic rhinitis, epistaxis and aseptic meningitis.
Dental & Medical Considerations: Not recommended pregnancy, lactation.
Nabumetone & Etodolac (pregnancy C).
Drug Interactions: Same as other NSAIDs plus decreases antihypertensive effects betablockers, hydralazine and captopril. Increases serum potassium of potassium sparing
diuretics. Nephrotoxic with cyclosporine. Increases toxicity of digoxin and
aminoglycosides. Probenecid increases this medications serum concentration.
Indomethacin (Indocin)
Diclofenac (Cataflam, Voltaren)
Nabumetone (Relafen)
Etodolac (Lodine)
Sulindac (Clinoril) Tendinitis, bursitis and ankylosing spondylitis.
White spots
mouth or lips, aphthous stomatitis, glossitis.
 Other NSAIDs
Diflunisal (Dolobid)
Use: Mild to moderate pain
Dental Considerations: Dry mouth, headache and blood dyscrasias. No pregnancy,
lactation.
Medical Considerations: >10%; fluid retention. 1-10%; GI ulceration.
Medical Considerations: Other adverse reactions; convulsions, stimulation, drowsiness,
dizziness, confusion, flushing, hallucinations, coma, pulmonary edema, rapid pulse,
vomiting, diarrhea, heartburn, hepatitis, anorexia, wheezing, hyperpnea and blurred
vision. Other adverse reactions; decreased acuity, corneal deposits, rash, urticaria,
bruising, hypoglycemia, hyponatremia and hypokalemia.
Drug Interactions: Decreased effect with antacids. Increased toxicity with digoxin,
methotrexate, anticoagulants, phenytoin and sulfonylureas. Increased toxicity with
sulfonamides, indomethacin, hydrochlorothiazide, lithium and acetaminophen.
Precautions: Don’t use if GI bleeding, PUD, possibility of Reyes syndrome. Minimal
effect on platelets, greater uricosuric effect.
Piroxicam (Feldene)
Use: Arthritis, including gouty arthritis.
Dental Considerations: Stomatitis, bleeding, dry mouth, blood dyscrasias, headache and
tinnitus. Local anesthesia with vasoconstrictor ok. Don’t use if pregnant or breastfeeding.
Medical Considerations: >10%; dizziness, skin rash, abdominal cramps, heartburn,
indigestion, and nausea.
Medical Considerations: 1-10%; nervousness, itching, fluid retention, vomiting.
70
Non-Narcotic Analgesic
 Other NSAIDs
Piroxicam (Feldene) continued
Medical Considerations: Other adverse reactions; drowsiness, insomnia, depression,
malaise, somnolence, nervousness, vertigo, peripheral edema, nausea, anorexia,
vomiting, diarrhea, cholestatic hepatitis, jaundice, constipation, flatulence, peptic ulcer,
epigastric distress, GI bleeding, nephrotoxicity, hematuria, oliguria, azotemia, hearing
loss, blurred vision, purpura, rash, pruritis, sweating, photosensitivity, elevated
ALT/AST and hypoglycemia.
Drug Interactions: GI ulcer, bleeding with aspirin, alcohol and corticosteroids.
Nephrotoxicity with acetaminophen (prolonged use, high dose). Decreased action
salicylates. Risk of increased effects oral anticoagulants, oral antidiabetics, lithium and
methotrexate. Decreased antihypertensive effects of diuretics, B-adrenergic blockers
and ACE inhibitors. Decreased effect with aspirin, antacids and cholestyramine
Precautions: Asthma, renal and hepatic disease, children, bleeding disorders, GI
disorders, cardiac disorders, hypertension.
Mefenamic Acid (Ponstel)
Use: Short term relief of mild to moderate pain including dysmenorrhea.
Dental Considerations: Local anesthesia with vasoconstrictor ok..
Headache, tinnitus, erythema multiforme, Stevens-Johnson syndrome, blood dyscrasias.
Dental Drug Interactions: Increases effects of oral anticoagulants.
Decreased effect with aspirin.
 COX-2 Inhibitor NSAIDs
Action: NSAIDs inhibit isoenzymes cyclooxygenase-1, COX-1, and
cyclooxygenase-2, COX-2. This inhibits prostaglandin synthesis. These
drugs have no effect on COX-1, which causes most of GI side effects of
NSAIDs.
Use: Signs and symptoms of osteoarthritis, mild acute pain and primary
dysmenorrhea.
Dental Considerations: Local anesthesia with vasoconstrictor ok.
Sinusitis, headache, aphthous stomatitis, dry mouth, oral ulcer, blood
dyscrasisas, chills, tinnitus, arthralgia, myalgia, hypesthesia, paresthesia,
post extraction alveolitis.
Dental Drug Interactions: Don’t use with aspirin, increased activity of
oral anticoagulants.
Medical Considerations and Drug Interactions: Same as other NSAIDs.
Celecoxib (Celebrex) only can use for arthritis.
Rofecoxib (Vioxx) Introduced May 21, 1999.
71
Non-Narcotic Analgesic
 Other NSAIDs
 Para-aminophenol derivatives
Action: Inhibits prostaglandin synthesis, more effectively in CNS than peripherally.
Thus is analgesic and antipyretic, but not anti-inflammatory. Also no gastric bleeding,
no effect on platelet adhesion or uric acid excretion.
Use: Treat mild pain and fever.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Blood dyscrasias.
Pregnancy and lactation ok.
Medical Considerations: Uncommon adverse reactions; stimulation, drowsiness,
hepatotoxicity, nausea, vomiting, abdominal pain, angioedema, rash and urticaria.
Medical Considerations: Toxicity shown with cyanosis, anemia, neutropenia, jaundice,
pancytopenia, CNS stimulation, delirium; then vascular collapse, convulsions, coma
and death.
Dental Drug Interactions: Barbiturates liver toxicity of high doses of acetaminophen.
Therapeutic doses with alcohol may cause severe hepatic toxicity. Nephrotoxicity with
long-term consumption especially if combined with NSAIDs. Buffered
acetaminophen decreases tetracycline absorption.
Medical Drug Interactions: Cholestyramine reduces effect. Hepatic toxicity possible
with INH and Dilantin.
Precautions: Don’t use with G-6-PD deficiency, alcoholics and liver disease.
Acetaminophen (Tylenol, Aspirin Free Anacin, Tempra)
 Acetaminophen Combinations
Acetaminophen and Diphenhydramine (Excedrin P.M., Midol
P.M.)
Action: Acetaminophen is analgesic and antipyretic. Diphenhydramine (Benadryl) is H1 blocker, decongestant.
Use: Treat mild to moderate pain, sinus headache.
Main side effect dry mouth. Others same as individual components.
Non-Narcotic Analgesic?
Tramadol (Ultram)
Action: Binds to Upsilon opiate receptors in CNS and inhibits reuptake of
norepinephrine and serotonin. This inhibits ascending pain pathways and alters
perception and response to pain.
Use: Treat moderate to severe pain.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Dry mouth, stomatitis
and headache. Don’t use if pregnant, lactation.
Medical Considerations: >1%; dizziness, somnolence, restlessness, nausea,
constipation, sweating.
72
Non-Narcotic Analgesic?
Tramadol (Ultram) continued
Medical Considerations: Other adverse reactions; vertigo, seizures, anxiety, confusion,
vasodilatation, palpitation, vomiting, dyspepsia, diarrhea, flatulence, urinary retention,
frequency, visual disturbances, pruritis, sweating, rash hypertonia and malaise.
Dental Drug Interactions: Increased risk respiratory depression with anesthetics and
alcohol. Increased risk sedation with other CNS depressants and alcohol.
Medical Drug Interactions: Decreased activity with carbamazepine. Increased activity
with cimetidine and quinidine. Increased risk of seizures MAO inhibitors, TCAs and
serotonin reuptake inhibitors.
Precautions: Can’t use if allergic to opiods. Don’t use if acute intoxication with
alcohol, hypnotics, centrally acting analgesics, psychotropic drugs or opiods. While
not a controlled substance dependence and abuse are possible. Greater risk with
elderly, chronic respiratory disorders, liver and renal disease, children, myxedema,
hypothyroidism and hypoadrenalism.
Narcotic Analgesic
 Opium Alkaloid +
Hydrocodone and Acetaminophen (Anexia, Bancap, Co-Gesic,
Lorcet, Lortab and Vicodin)
Action: Hydrocodone is opiate analgesic, binds to Mu and Kappa opiate receptors in
cerebral cortex and blocks pain perception. In medulla suppresses cough center.
Action: Acetaminophen is prostaglandin inhibitor with analgesic and antipyretic
activity.
Use: Treat moderate to severe pain. Class III narcotic.
*Hydrocodone and Acetaminophen
*Dental Considerations: Local anesthesia with vasoconstrictor ok. Dry mouth,
headache and tinnitus. Better than codeine for pregnancy, but not great. No with
breast-feeding (codeine ok).
*Medical Considerations: >10%; hypotension, lightheadedness, dizziness and sedation.
1-10%; nausea.
*Medical Considerations: Other adverse reactions; convulsions, euphoria, dysphoria,
weakness, hallucinations, disorientation, circulatory depression, palpitations,
tachycardia, bradycardia, change in BP, syncope, anorexia, vomiting, constipation,
cramps, respiratory depression, dysuria, increased urinary output, urinary retention,
blurred vision, miosis, diplopia, rash, urticaria, flushing and pruritis.
*Dental Drug Interactions: Allergic cross reactions with other phenanthrene derivatives
(morphine, codeine, levorphanol, oxycodone and oxymorphone). Increased CNS
depression with alcohol, phenothiazines, sedative/hypnotics, skeletal muscle relaxants,
general anesthetics and other opiods. Increased effects of anticholinergics, may cause
paralytic ileus.
*Medical Drug Interactions: Use of antidepressants (MAO inhibitors or TCAs) and
hydrocodone can increase effects of both antidepressant and hydrocodone.
73
Narcotic Analgesic
 Opium Alkaloid +
Hydrocodone and Acetaminophen (Anexia, Bancap, Co-Gesic,
Lorcet, Lortab and Vicodin) (Continued)
Precautions: Don’t use if G-6-PD deficiency. Use with caution if respiratory diseases
(asthma, emphysema, COPD), severe liver or renal insufficiency. Many preparations
contain sulfites, watch for allergic reactions.
Hydrocodone and Aspirin (Lortab ASA)
Same action, use, considerations, drug interactions, and precautions as individual
components.
Acetaminophen and *Codeine (Capital and Codeine,
Phenaphen with Codeine, Tylenol with Codeine) *More nausea,
vomiting and constipation than with Hydrocodone. Same action and use as
Hydrocodone. Similar considerations, drug interactions and precautions as individual
components. Codeine acts as hydrocodone.
Acetaminophen and *Oxycodone (Percocet, Tylox)
*Class II narcotic. Same use and action as individual components with Oxycodone
acting as Hydrocodone. More side effects than with Hydrocodone. Dry mouth more
common. * >10%: Fatigue, drowsiness, dizziness, nausea and vomiting. 1-10%:
Anorexia, stomach cramps, xerostomia, constipation and biliary spasm.
Aspirin and Oxycodone (Percodan)
Same action, use and side effects as individual components.
Morphine Sulfate (MS Contin, Roxanol)
Action: Binds to opiate receptors in CNS to depress pain impulse transmission.
Use: Severe pain
Dental Considerations: Local anesthesia with vasoconstrictor ok. Dry mouth,
headache, TMJ-tinnitus,
Dental Drug Interactions: Increases effect of other CNS depressants, anticholinergics
 Synthetic
Meperidine (Demerol)
Action: Binds to mu and kappa opiate receptors in CNS, inhibiting ascending pain
pathways. Alters pain perception and response. Produces generalized CNS
depression.
Use: Moderate to severe pain. Alternative if allergic to codeine. Preoperatively in
sedation techniques.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Dry mouth, headache
and tinnitus. Better than codeine/hydrocodone if pregnant, ok with lactation.
Medical Considerations: >10%; Hypotension, fatigue, drowsiness, dizziness, nausea,
vomiting, constipation, weakness and histamine release.
Medical Considerations: Less common; Confusion, sedation, euphoria, increased
intracranial pressure, palpitation, bradycardia, change in BP, tachycardia (IV),
74
Narcotic Analgesic
 Synthetic
Meperidine (Demerol) (Continued)
Medical Considerations: anorexia, cramps, respiratory depression, increased urinary
output, dysuria, urinary retention, blurred vision, miosis, diplopia,
depressed corneal reflex, rash, urticaria, bruising, flushing, diaphoresis and pruritis.
Dental Drug Interactions: Increased effects with all CNS depressants, anticholinergics.
Medical Drug Interactions: Effect increased by MAO inhibitors, TCAs, phenothiazine,
fluoxetine ant other serotonin uptake inhibitors.
Medical Drug Interactions: Dilantin decreases effect. Aggravates adverse effects of
isoniazid. Don’t use if MAO inhibitor given in previous 14 days, not with Eldepryl.
Precautions: Use with caution with pulmonary, hepatic and renal disorders, history of
seizures. Some preparations contain sulfides; watch out if allergic to sulfides.
 Synthetic +
Meperidine and Promethazine (Mepergan)
Same action, use and effects as individual components. Main side effect is dry mouth.
 Synthetic, Meperidine Group
Fentanyl Transdermal System (Duragesic Patches)
Action: Same as Meperidine.
Use: Management of chronic pain.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Dry mouth,
dysesthesias. Orthostatic hypotension and laryngospasm.
Medical Considerations: >10%; Hypotension, bradycardia, CNS depression,
drowsiness, sedation, nausea, vomiting, constipation and respiratory depression.
Medical Considerations: 1-10%; cardiac arrhythmias, confusion, biliary tract spasm,
miosis.
Medical Considerations: <1%; Circulatory depression, convulsions, paradoxical CNS
excitation or delirium, dizziness, erythema, pruritis, rash, hives, itching, cold and
clammy skin, urinary tract spasm, bronchospasm and muscle rigidity.
Dental Drug Interactions: Effects increased with other CNS depressants and skeletal
muscle depressants. Increased anticholinergic effect with anticholinergics. Additive
hypotension with nitrous oxide and benzodiazepines.
Medical Drug Interactions: Effects increased by chlorpromazine and cimetidine.
Additive hypotension with phenothiazines.
Precautions: Don’t use with myasthenia gravis. Use with caution with respiratory
depression, severe liver or renal insufficiency and bradycardia.
Elderly more prone enhanced analgesia, CNS depression and constipation. Pregnancy
B (D if high dose at term or for prolonged period).
75
Narcotic Analgesic
 Synthetic, Methadone Group
Propoxyphene (Darvon, Darvon-N)
Action: Binds to opiod receptors in CNS, blocking pain.
Use: Treat mild to moderate pain.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Dry mouth, headache
and tinnitus. No if pregnant, ok with lactation.
Medical Considerations: >10%; Hypotension, dizziness, lightheadedness, sedation,
paradoxical excitement, insomnia, fatigue, drowsiness, GI upset, nausea, vomiting,
constipation, weakness and histamine release.
Medical Considerations: 1-10%; Nervousness, restlessness, malaise, confusion,
anorexia, stomach cramps, biliary spasm, decreased urination, uretal spasms and
dyspnea.
Medical Considerations: <1%; Mental depression, hallucinations, paradoxical CNS
stimulation, increased intracranial pressure, rash, urticaria, paralytic ileus.
Dental Drug Interactions: Decreased effect with charcoal (cigarettes). Increased
toxicity with other CNS depressants and skeletal muscle relaxants. Increases effects of
warfarin and anticholinergics.
Medical Drug Interactions: Increases effects of carbamazepine, barbiturates, MAO
inhibitors and TCAs.
Precautions: Severe hepatic and renal disease, respiratory depression and alcoholism.
Pregnancy risk factor C (D if prolonged use), Psychological and physical dependence
with prolonged use.
 Synthetic, Methadone Group+
Propoxyphene and Acetaminophen (Darvocet-N, Darvocet-N
100, Propacet, Wygesic) Effects same as individual components.
 Synthetic, Methadone Group+
Propoxyphene and Aspirin (Darvon Compound-65 Puvules)
Effects same as individual components.
 Synthetic, Benzomorphan Group
Pentazocine (Talwin, Talwin NX)
Action: Binds to Kappa and Delta opiate receptors (agonist), decreasing pain.
Antagonist to Mu opiate receptor.
Use: Moderate to severe pain, preoperative sedative and supplement to surgical
anesthesia.
Dental Considerations: Local anesthesia with vasoconstrictor ok. Dry mouth, headache
and tinnitus. Pregnancy ok, except near term (neonatal respiratory depression),
lactation no.
76
 Synthetic, Benzomorphan Group
Pentazocine (Talwin, Talwin NX) (Continued)
Medical Considerations: >10%; Euphoria, drowsiness, nausea, vomiting and
weakness.
Medical Considerations: 1-10%; Hypotension, restlessness, nightmares, skin rash,
ureteral spasm, blurred vision and dyspnea.
Medical Considerations: <1%; Palpitations, bradycardia, peripheral vasodilatation,
insomnia, CNS depression, sedation, hallucinations, confusion, disorientation, seizures
if history, increased intracranial pressure, pruritis, antidiuretic hormone release, GI
irritation, constipation, biliary spasm, urinary tract spasm, miosis and histamine
release.
Dental Drug Interactions: Increased effect of CNS depressants. May potentiate or
reduce analgesic effect of opiate. Can cause withdrawal in narcotic addicts. Increased
effects of anticholinergics.
Medical Drug Interactions: Don’t give with MAO inhibitors. Can be lethal with
antihistamine tripelennamine (PBZ, PBZ-SR).
Medical Drug Interactions: Increased effect with phenothiazines.
Precautions: Pregnancy category B (D long term or high dose), lactation, severe renal
and hepatic disease and Addison’s disease. Prostatic hypertrophy and respiratory
depression. NX means naloxone added decreases addictive potential, euphoria.
Increases withdrawal risk.
77
INTERACTION BETWEEN SPECIFIC DISEASES AND
DENTAL PHARMACOLOGY
 Ischemic Heart Disease
Angina pectoris: Don’t give anticholinergics (Probanthine), increases cardiac rate
and oxygen demand, arrhythmias possible.
Previous myocardial infarction (MI): Don’t give aspirin or other NSAIDs for post
-op pain. If surgery and MD oks may want to be off aspirin 7-10
days pre-op.
 Asthma
Attacks stimulated by aspirin, NSAIDs, barbiturates,
Narcotics and cold air.
If taking theophylline no macrolide antibiotics (Erythromycin, Azithromycin or
Clarithromycin) or Ciprofloxacin, may cause theophylline toxicity.
Antihistamines should be used with caution due to drying effects.
Local anesthetics with epinephrine or levonordefrin contain sulfite preservatives,
may cause asthma attack.
Oral candidiasis possible with steroid inhalers.
If taking oral corticosteroids for one week in last six months may be adrenal
suppressed. If stressful procedure Adrenal Supplementation Regimen is to double
normal steroid dose day of procedure and first postoperative day.
Stress may cause asthma attack. Premedication with oral diazepam ok. Nitrous
Oxide during procedure is excellent, not a respiratory depressant and doesn’t
irritate tracheobronchial tree.
Have patient bring asthma medications to appointment. Ask if any asthma
symptoms prior to dental treatment.
 COPD
Avoid nitrous oxide, high oxygen flow may depress respiratory drive. Also nitrous
oxide accumulates in enlarged air spaces in lung with emphysema. If must use
oxygen use at low 2-4 liter flow rate.
Anticholinergics and antihistamines cause drying which increases mucous tenacity,
so don’t use. Narcotics and barbiturates can cause respiratory depression.
Watch for concomitant CAD and hypertension. If taking oral steroids may need to
follow Adrenal Supplementation Regimen. No office GA or IV sedation.
78
 COPD (continued)
If taking theophylline no macrolide antibiotics (Erythromycin, Azithromycin or
Clarithromycin) or Ciprofloxacin, may cause theophylline toxicity.
 Diabetes Mellitus
NPO rules for general anesthesia. Stop medications evening before surgery. Longer
acting oral agents must be stopped sooner. Glyburide (Diabeta, Micronase) stop 24
hours pre-op, Chlorpropamide (Diabinese) 36 hours and Metformin (Glucophage)
48 hours.
 Bleeding Disorders, GI Disease
Avoid aspirin, aspirin compounds and NSAIDs. Use acetaminophen and codeine.
 Kidney Failure
Heparin given during dialysis can cause bleeding problems. Perform dental surgical
procedures 4-30 hours after dialysis and 24-48 hours prior to next dialysis.
Avoid nephrotoxic drugs: NSAIDs, aminoglycosides, acyclovir, radiographic
contrast media. Meperidine and propoxyphene converted to renal toxic metabolites,
don’t use. Penicillin G and magnesium citrate have excessive electrolytes, don’t use.
Reduce dose of ketoconazole. Increase interval between doses with aspirin,
Acetaminophen, penicillin V, cephalexin and tetracycline.
No problems using the following drugs: Codeine, erythromycin, valium,
clindamycin and metronidazole (Flagyl).
 Liver Failure
Dental drugs metabolized primarily by the liver: Local anesthetics; Lidocaine
(Xylocaine), Mepivacine (Carbocaine), Prilocaine (Citanest) and Bupivacaine
(Marcaine). Analgesics; Aspirin, Acetaminophen, Codeine, Meperidine (Demerol)
Ibuprofen (Motrin) and Propoxyphene (Darvon). Sedatives; Diazepam (Valium)
and Barbiturates. Antifungals; Ketoconazole. Antibiotics: Ampicillin, Penicillin,
Erythromycin, Clindamycin, Metronidazole and Tetracycline.
Most drugs used in dentistry metabolized by liver. Unless severe hepatic
Dysfunction can use drugs in limited quantity (Three cartridges 2% lidocaine is
108 mg, ok).
 Immunocompromised
HIV+: No antibiotic prophylaxis necessary.
AIDS: Antibiotic prophylaxis.
79
 Immunocompromised (continued)
HIV Drugs:
Protease inhibitors ritonavir (Norvir), indinavir (Crixivan), Saquinavir (Invirase)
and benzodiazepines increase benzodiazepine levels. Adjust benzodiazepine dose
or don’t use. Azole antifungals, ketoconazole, clarithromycin mixed with protease
inhibitors can be cardiotoxic with fatal arrhythmias. Produces large increases in
concentrations of meperidine and propoxyphene, don’t use with protease inhibitors.
Metronidazole and liquid ritonavir (contains alcohol) get disulfarim (Antabuse)
like reaction.
Some antihistamines) mixed with protease inhibitors can be cardiotoxic with fatal
arrhythmias.
Organ Transplant Drugs:
Follow Adrenal Supplementation Regimen if on steroids and procedure is
stressful.
Cyclosporin is hepatotoxic, neurotoxic and causes hypertension and gingival
hyperplasia.
Azathioprine (Imuran) causes hepatotoxicity, thrombocytopenia and leukopenia.
Mycophenolate (CellCept) causes leukopenia. Don’t use NSAIDs,
aminoglycosides and acyclovir with mycophenolate as causes nephrotoxicity.
Tarcolimus, a potent macrolide immunosuppressant, is nephrotoxic, neurotoxic
and diabetogenic. Macrolide antibiotics, azole antifungals and corticosteroids
Increase tarcolimus concentration.
Antihistamines terfenadine (Seldane) and astemizole (Hismanal) cause cardiac
arrhythmias when used with tacrolimus and cyclosporine.
If WBC < 2,000 need antibiotic prophylaxis.
 Pregnancy
Anesthesia
No office sedation or general anesthetics. No nitrous oxide, chronic
exposure increases spontaneous abortions. Local anesthesia fine.
Acetaminophen drug of choice. Therapeutic short-term meperidine (Demerol)
And fentanyl fine. Oxy/hydrocodone not bad. Propoxyphene not good.
Codeine causes congenital anomalies.
80
 Pregnancy
Analgesia (continued)
Aspirin causes anemia, antepartum or postpartum hemorrhage and intracranial
fetal hemorrhage. Pentazocine (Talwin) no congenital defects, but may cause
severe neonatal respiratory depression, avoid giving near term. Avoid NSAIDs
during third trimester and new research suggests throughout pregnancy.
Antibiotics
Penicillins, cephalosporins, erythromycin and clindamyacin not teratogenic.
Don’t use aminoglycosides, tetracycline, metronidazole and sulfonamides.
Corticosteroids
Increases risk of maternal infection and neonatal sepsis, don’t use.
Anticholinergics
Don’t use Pro-Banthine.
Muscle Relaxants
Cyclobenzaprine (Flexeril) one of only possible drugs to use.
 Lactation
Amount of drug in breast milk usually not more than 1-2% maternal dose.
Don’t use aspirin, tetracycline, barbiturates or benzodiazepines. No consensus
on NSAIDs, oxy/hydrocodone, pentazocine and muscle relaxants, so should
probably avoid. All other drugs commonly used in dentistry ok, codeine ok,
nitrous oxide ok.
Breast feeding instructions. Instruct mother to take drugs just after breast
Feeding and avoid nursing for four or more hours after taking drugs. Pre-op
Pumping and storing milk good.
 Hypothyroid
Untreated very sensitive to sedatives and opiods, use non-narcotic analgesics.
Well controlled, no treatment problems.
 Adrenal Insufficiency
If taking steroids and stressful procedure follow Adrenal Supplementation
Regimen. Steroids also delay healing, cause hypertension, more susceptible
to infection.
 Sickle Cell Anemia
Chronic anemia, increased severity of dentoalveolar infections, osteomyelitis,
81
 Sickle Cell Anemia (continued)
poor healing.
Increased anesthesia risk so not good candidates for office IV.
sedation or GA. Local anesthesia without vasoconstrictor ok. If
surgery vasoconstrictor ok, aspirate well. Nitrous oxide controversial. If
use must have at least 50% oxygen, watch for diffusion hypoxia.
High dose salicylates cause acidosis. Acetaminophen and small doses of
Codeine drug of choice for pain control.
 G-6-PD Deficiency
G-6-PD MED, drugs usually trigger mostly sulfonamides, aspirin, phenacetin
and chloramphenicol. Also penicillin, streptomycin and isoniazid.
 Substance Abuse
Alcohol
CNS depressant, increases effects of narcotics, benzodiazepines and
barbiturates.
Chronic users may require greater anesthetic dosages.
Avoid narcotics as often multiple addictions.
Therapeutic doses of acetaminophen mixed with alcohol may cause liver
failure.
Opiods
Medical problems include liver disease and infectious diseases (HIV,
infectious hepatitis and endocarditis). Intravenous drug use history, consider
antibiotic prophylaxis.
High tolerance to pain medication, difficult IV access, behavior problems
and higher dose requirements of anesthetic agents. If on methadone, take
pre-op. Droperidol good for dissociative effect.
Avoid narcotic antagonists, may cause withdrawal (Talwin NX). Can
develop profound hypotension during IV sedation and GA.
Heroin causes xerostomia, cervical caries.
Management principals: Agree prior to procedure on type and time on
narcotics. If cured addict (any substance) avoid narcotics, NSAIDs
preferred.
82
 Seizure Disorder
Phenytoin, carbemazepine and valpoic acid may cause leukopenia and
thrombocytopenia. Don’t use NSAIDs with these medications. No
propoxyphene or erythromycin with carbemazepine.
 Stroke
Coumadin monitor by PT or INR.
Aspirin or antiplatelet drugs (dipyridamole) monitor by bleeding time: >10
minutes, slightly increased bleeding risk, >20 minutes, significant bleeding risk.
 Arthritis
Aspirin and NSAIDs watch for bleeding.
If rheumatoid arthritis may be taking gold salts, penicillamine,
immunosuppressives or sulfasalazine causing stomatitis.
If stomatitis with bleeding and ulceration watch for blood dyscrasias; anemia,
agranulocytosis or thrombocytopenia.
If steroids may need supplementation.
If joint prosthesis antibiotic prophylaxis.
 Allergies and Congestion
Antihistamines have additive CNS depression with CNS depressants and
alcohol. Increased anticholinergic effects with anticholinergics and other
antihistamines.
Don’t use ketoconazole or erythromycin with antihistamines, can result in liver
damage and cardiac arrhythmias with possible fatalities.
No arrhythmias reported with loratadine (Claritan), fexofenadine (Allegra),
clemastine (Tavist), diphenhydramine (Benadryl), meclizine (Antivert).
Reported problems with cetirizine (Zyrtec).
Decongestants, don’t use local anesthetic with vasoconstrictor, can cause
pressor response. Sedation with CNS depressants and Alcohol. Arrhythmias
with inhalation anesthetics. Medications include Pseudoephedrine (Sudafed,
Actifed Tabs, Afrin Tabs, Triaminic), Oxymetazoline (Afrin) and Ephedrine.
83
VASOCONSTRICTORS
 Cardiovascular Disease
Healthy adult can receive up to 0.2 mg of epinephrine within 15 minutes. Each c.c.
of 1:100,000 epinephrine contains 0.01 mg. Carpule is 1.8cc, so contains 0.018 mg.
No more than 10 carpules in 15 minutes.
Vasoconstrictor Precautions: With cardiovascular disease limit to 0.04 mg
epinephrine or 0.2 mg levonordefrin in 15 minutes, no more than 2 carpules.
With cardiovascular disease don’t use gingival retraction cord containing
epinephrine. Don’t use 1:50,000 epinephrine. Avoid intraligamental and
intraboney injections with vasoconstrictor local anesthetics.
Avoid vasoconstrictors if taking noncardioselective beta-blockers: Carteolol
(Cartrol, Ocupress), Carvedilol (Coreg), Nadolol (Corgard), Penbutolol (Levatol),
Pindolol (Visken), Propranolol (Inderal) and Timolol (Blocadren). Can use
1:100,000 epinephrine if monitor pre and post injection vital signs, give ½ carpule,
wait 5 minutes, if no change can repeat process. Can use levonordefrin in same
manner.
If patient taking Digoxin (Lanoxin) check with physician prior to using
vasoconstrictor.
 Arrhythmia
Same Vasoconstrictor Precautions except if serious arrhythmia don’t use
vasoconstrictor in local anesthetic.
 Psychiatric Disorders
Potential for hypertensive crisis, myocardial infarction mixing vasoconstrictors
with neuroleptic and heterocyclic medications.
Neuroleptic agents (Antipsychotic drugs) are Chlorpromazine (Thorazine),
Fluphenazine (Permitil), Trifluoperazine (Stelazine), Mesoridazine (Serentil),
Haloperidol (Haldol), Molindone (Moban). If patient is not acutely hypotensive
due to these medications and can avoid intravascular injections, can use
vasoconstrictors in normal dosages. Hypotensive reaction can result from alpha
adrenergic blockade and increase epinephrine results in only beta-2 vasodilative
effects.
Heterocyclics (TCAs) are Amitriptyline (Elavil), Imipramine (Tofranil),
Amoxapine (Asendin), Maprotiline (Ludiomil). If use 1:100,000 epinephrine give
no more than 1/3 maximum dose. Additional dosages after 30 minutes. Don’t use
levonordefrin (Carbocaine with Neocobefrin). Some gingival retraction cords
contain large amounts of epinephrine, don’t use.
84
 Psychiatric Disorders (continued)
MAO inhibitors are Phenelzine (Nardil), Isocarboxazid (Marplan) and
Tranylcypromine (Parnate). Use local anesthesia without vasoconstrictor
whenever possible. If must use limit to two carpules 1:100,000 epinephrine
within 15 minutes, aspirate.
 Substance Abuse
Stimulants, Cocaine and Methamphetamine
Local anesthesia with vasoconstrictor can cause life threatening arrhythmias and
hypertensive crisis. General anesthetics can be dangerous as are mixing with
psychotropic drugs.
 Miscellaneous Vasoconstrictor Interactions
Don’t use vasoconstrictor if patient has:
1. Pheochromocytoma
2. Hyperthyroid
3. Significant risk with phenylephrine (OTC cold medication)
4. Phentermine (Fastin)
5. Ritalin if patient is hypertensive
Use with caution if:
1. General anesthetic agents; Halothane (Fluothane), Enflurane (Etharane),
Isoflurane (Forane) and Thiopental (Pentothal). Check with anesthesiologist
to see if can use and in what amounts.
2. Guanethidine (Ismelin) and Guanadrel (Hylorel) antihypertensives follow TCA
precautions.
85
Dental Drug Interactions
 Antibiotics
Penicillin Derivatives: Tetracyclines, erythromycin and clindamycin decrease
effectiveness. Acts synergistically with aminoglycosides. Probenecid will increase
blood levels.
Penicillin, Amoxicillin, Ampicillin, (Augmentin), and (Unasyn)
Macrolide: Decreases action of clindamycin, penicillins and oral contraceptives.
Increases effects of oral anticoagulants and benzodiazepines. Medical; increases
effects of alfentanil, carbamazepine, theophylline, felodipine, triazolam and
ergotamine. Contraindicated with azole antifungals, statins, theophylline,
(Erythromycin and Clarithromycin).
Erythromycin, Clarithromycin (Biaxin) and Azithromycin
(Zithromax)
Lincomycin Derivatives: Decreases activity of erythromycin, increases activity of
nondepolarizing muscle relaxants and hydrocarbon inhalation anesthetics.
Clindamyacin (Cleocin)
Cephalosporins: Decreased bactericidal effects with tetracyclines and erythromycin.
May reduce effectiveness of oral contraceptives. Probenecid decreases elimination.
Cephalexin (Keflex, Keftab) 1st generation
Cefadroxil (Duricef) 1st generation
Cefprozil (Cefzil) 2nd generation
Cefuroxime (Ceftin) 2nd generation
Cefaclor (Ceclor) 2nd generation
Loracarbef (Lorabid) 2nd generation
Cefpodoxime (Vantin) 2nd generation
Cefixime (Suprax) 3rd generation
Tetracycline Derivatives: Decreases effect of penicillin, cephalosporin, oral
contraceptives. Increases oral anticoagulant effect. Absorption reduced by dairy
products, calcium, magnesium or aluminum containing antacids, iron, zinc, and
cimetidine. Outdated drug can cause nephropathy. If give with Methoxyflurane
anesthesia can cause fatal nephrotoxicity.
Tetracycline (Achromycin, Sumycin, Tetracyn)
Minocycline (Minocin)
Doxycycline (Vibramycin)
Tetracycline Periodontal Fibers (Actisite)
86
 Antifungals
Fluconazole (Diflucan)
Increases coumadin and benzodiazepine activity. Rifampin decreases fluconazole
activity. Arrhythmias possible with antihistamines.
Metronidazole (Flagyl)
None with Disulfiram (Antabuse), causes psychosis.
Clotrimazole (Mycelex Troche)
Increases activity of cyclosporines and sulfonylureas.
 Antivirals
Acyclovir (Zovirax)
Increased CNS side effects with zidovudine (AIDS drug) and probenecid.
 Non-Narcotic Analgesic
Non-Steroidal Anti-inflammatory Drugs (NSAIDs)
Salicylate NSAIDs
Increases bleeding risk with oral anticoagulants. Avoid corticosteroids and
Acetaminophen. Can cause toxicity of Diamox (CNS) and methotrexate (hepatic).
Increased GI bleeding and complaints with alcohol. Increased risk bleeding valproic
acid, dipyridamole. Increased toxicity lithium and zidovudine. Decreased effects
of probenecid and sulfinpyrazone.
Acetylsalicylic Acid (Aspirin, Anacin, Bayer, Bufferin, Ecotrin,
Empirin)
Propionic Acid Derivative NSAIDs
Same as salicylates. Nephrotoxic with acetaminophen. Increased photosensitivity
with tetracycline. Increased toxicity diuretics. Not with methotrexate.
Ketoprofen (Orudis, Oruvail)
Oxaprozin (Daypro)
Naproxen (Aleve, Anaprox, Naprosyn)
Ibuprofen (Advil, Motrin, Midol, Nuprin, Rufen)
Acetic Acid Derivative NSAIDs
Same as other NSAIDs plus decreases antihypertensive effects beta-blockers,
hydralazine and captopril. Increases serum potassium of potassium sparing
Diuretics. Nephrotoxic with cyclosporine. Increases toxicity of digoxin and
Aminoglycosides. Probenecid increases this medications serum concentration. Not
with lithium or methotrexate.
87
Acetic Acid Derivative NSAIDs
(continued)
Indomethacin (Indocin)
Diclofenac (Cataflam, Voltaren)
Nabumetone (Relafen)
Etodolac (Lodine)
Sulindac (Clinoril)
Other NSAIDs
Diflunisal (Dolobid)
Decreased effect with antacids. Increased toxicity with digoxin, methotrexate,
anticoagulants, phenytoin and sulfonylureas. Increased toxicity with sulfonamides,
indomethacin, hydrochlorothiazide, lithium and acetaminophen.
Piroxicam (Feldene)
GI ulcer, bleeding with aspirin, alcohol and corticosteroids. Nephrotoxicity with
Acetaminophen (prolonged use, high dose). Decreased action salicylates. Risk of
increased effects oral anticoagulants, oral antidiabetics, lithium and methotrexate.
Decreased antihypertensive effects of diuretics, B-adrenergic blockers and ACE
inhibitors. Decreased effect with aspirin, antacids and cholestyramine.
Mefenamic Acid (Ponstel)
Increases effects of oral anticoagulants. Decreased effect with aspirin. None with
corticosteroids, methotrexate and lithium.
Cox-2 Inhibitors
Don’t use with aspirin, increased activity of oral anticoagulants. Other reactions
Same as other NSAIDs.
Celecoxib (Celebrex)
Rofecoxib (Vioxx)
Para-aminophenol Derivates
Barbiturates liver toxicity of high doses of acetaminophen. Therapeutic doses with
alcohol may cause severe hepatic toxicity. Nephrotoxicity with long-term
consumption especially if combined with NSAIDs. Buffered acetaminophen
decreases tetracycline absorption. Cholestyramine reduces effect. Hepatic toxicity
possible with INH and Dilantin.
Acetaminophen (Tylenol, Aspirin Free Anacin, Tempra)
88
 Non-Narcotic Analgesic?
Tramadol (Ultram)
Increased risk respiratory depression with anesthetics and alcohol. Increased risk
sedation with other CNS depressants and alcohol. Decreased activity with
carbamazepine. Increased activity with cimetidine and quinidine. Increased risk of
seizures MAO inhibitors, TCAs and serotonin reuptake inhibitors.
 Narcotic Analgesic
Opium Alkaloid +
Hydrocodone and Acetaminophen (Anexia, Bancap, Co-Gesic,
Lorcet, Lortab and Vicodin)
*Hydrocodone and Acetaminophen
*Allergic cross reactions with other phenanthrene derivatives (morphine, codeine,
levorphanol, oxycodone and oxymorphone). Increased CNS depression with alcohol,
phenothiazines, sedative/hypnotics, skeletal muscle relaxants, general anesthetics and
other opiods. Increased effects of anticholinergics, may cause paralytic ileus.
Use of antidepressants (MAO inhibitors or TCAs) and hydrocodone can increase
effects of both antidepressant and hydrocodone.
Hydrocodone and Aspirin (Lortab ASA)
Same drug interactions as individual components.
Acetaminophen and *Codeine (Capital and Codeine,
Phenaphen with Codeine, Tylenol with Codeine)
*Similar drug interactions as individual components. Codeine acts as hydrocodone.
Acetaminophen and *Oxycodone (Percocet, Tylox)
*Class II narcotic. Same drug interactions as individual components with Oxycodone
acting as Hydrocodone
Aspirin and Oxycodone (Percodan)
Same drug interactions as individual components, with Oxycodone acting as codeine.
Synthetic, Meperidine Group
Meperidine (Demerol)
Increased effects with all CNS depressants, anticholinergics. Effect increased by
MAO inhibitors, TCAs, phenothiazine, fluoxetine, cimetidine and other serotonin
Uptake inhibitors. Dilantin decreases effect. Aggravates adverse effects of isoniazid.
Don’t use if MAO inhibitor given in previous 14 days.
Don’t use with Selegiline (Eldepryl), serotonin syndrome.
89
 Narcotic Analgesic
Synthetic, Meperidine Group
Fentanyl Transdermal System (Duragesic Patches)
Effects increased with other CNS depressants and skeletal muscle depressants.
Increased anticholinergic effect with anticholinergics. Additive hypotension with
nitrous oxide and benzodiazepines. Effects increased by chlorpromazine and
cimetidine. Additive hypotension with phenothiazines.
Synthetic, Methadone Group
Propoxyphene (Darvon, Darvon-N)
Decreased effect with charcoal (cigarettes). Increased toxicity with other CNS
depressants and skeletal muscle relaxants. Increases effects of warfarin and
anticholinergics.
Increases effects of carbamazepine, barbiturates, MAO inhibitors and TCAs.
Synthetic, Methadone Group+
Propoxyphene and Acetaminophen (Darvocet-N, Darvocet-N
100, Propacet, Wygesic) Same drug interactions as individual components.
Propoxyphene and Aspirin (Darvon Compound-65 Puvules)
Same drug interactions as individual components.
Synthetic, Benzomorphan Group
Pentazocine (Talwin, Talwin NX)
Increased effect of CNS depressants. May potentiate or reduce analgesic effect of
opiate. Can cause withdrawal in narcotic addicts. Increased effects of
anticholinergics. Don’t give with MAO inhibitors. Can be lethal with antihistamine
tripelennamine (PBZ, PBZ-SR). Increased effect with phenothiazines.
 Anti-Anxiety Agents
Benzodiazepines
CNS depressants (alcohol, barbiturates, opiods) enhance sedative and respiratory
depressant effects of this medication. Increased effect of medication by erythromycin
and antifungals. Increased medication effect with cimetidine, cisapride, valproic acid,
antihistamines and selective serotonin reuptake inhibitors, oral contraceptives.
Alprazolam (Xanax)
Diazepam (Valium)
Temazepam (Restoril)
Lorazepam (Ativan) Increased toxicity with MAO inhibitors, tricyclic
antidepressants, phenothiazines.
Clorazepate (Tranxene)
90
 Anti-Anxiety Agents
Benzodiazepines (continued)
Flurazepam (Dalmane)
Triazolam (Halcion)
 Skeletal Muscle Relaxant
Carisoprodol (Soma)
Increased CNS depression all CNS depressants. Increased CNS depression with
phenothiazines and MAO inhibitors.
Chlorzoxazone (Parafon Forte)
Increased CNS depression with alcohol, narcotics, barbiturates, sedatives, hypnotics.
Cyclobenzaprine (Flexeril)
Increased CNS depression with alcohol, narcotics, barbiturates, sedatives, hypnotics.
Increased effects of anticholinergics. Increased toxicity with TCAs. Increased effect
of direct acting sympathomimetics (epinephrine and levonordefrin).
Orphenadrine (Norflex)
Increased CNS depression with CNS depressants. Increased anticholinergic effect
with anticholinergics.
91
Question #1
How does Aldosterone work?
Specifically can you explain
the relationship of
Aldosterone to angiotensin,
renin and antidiuretic
hormone, vasopressin?
92
Question #2
What is Rhabdomyolysis?
93
Question #3
What’s with all these
different neurotransmitters
and how exactly do they
work?
94
Question #4
How much do you
know about pigs?
95
Question #5
Stop! (Pause)
I feel overloaded with
information! (Pause)
Before we start clinical cases,
can’t you logically explain
the patterns of drug
interactions?
96
It is my pleasure to welcome Michael L.
Iczkovitz, D.D.S. to The Northern
Nevada Dental Society. Dr. Iczkovitz is
a Diplomate of the American Board of
Oral and Maxillofacial Surgery and is in
the clinical practice of oral and
maxillofacial surgery in Ft. Wayne, IN.
He obtained his undergraduate and
dental school education at the University
of Michigan. He did a general practice
residency at the Michael Reese Medical
Center in Chicago. His oral and
maxillofacial surgery residency was at
the University of Pennsylvania in
Philadelphia. Dr. Iczkovitz has
presented this lecture to numerous dental
societies throughout the United States to
enhance the expertise and enjoyment of
the entire dental profession.
97