Top 20 most commonly prescribed meds

COURSE TITLE:
Managing the Oral Side Effects of Medication Use
COURSE INSTRUCTOR: Ann Eshenaur Spolarich, RDH, PhD
COURSE CREDITS:

COURSE DATE:
________________________________________________________________________
COURSE DESCRIPTION:
The purpose of this course is to review the 20 most commonly prescribed medications taken by
clients treated in the oral health care environment. In addition, drug interactions, popular drugs
in the media and new drugs in dentistry will be discussed. A comprehensive review of drugs and
dental care products used to manage the oral side effects of medications will be presented.
LEARNING OBJECTIVES:
Upon completion of this continuing education course, the participant will be able to:
1.
Identify and discuss commonly prescribed medications taken by clients treated in the oral health care setting. Identify common drug interactions of significance to dental professionals. List several new dental drugs and discuss their indications for use in practice. Discuss the management of oral side effects caused by medications. *This material may not be reproduced without the written permission of the author. TOP 20 MOST COMMONLY PRESCRIBED MEDS
2012 (Total Dollars in Sales)

1. Nexium
2. Abilify
3. Crestor
4. Advair Diskus
5. Cymbalta
6. Humira
7. Enbrel
8. Remicade
9. Copaxone
10. Neulasta
11. Singulair
12. Rituxan
13. Plavix
14. Atripla
15. Spiriva Handihaler
16. Oxycontin
17. Januvia
18. Avastin
19. Lantus
20. Truvada
INDICATIONS
Abilify (atypical antipsychotic), Cymbalta (SSRI) Humira, Enbrel, Remicade (TNF alpha blockers) Copaxone, Neulasta (colony stimulating factor) Advair Diskus, Singulair, Spiriva Handihaler Januvia (DPP-IV inhibitor), Lantus (long acting insulin) 2012 (Total Prescriptions Dispensed)
1. hydrocodone and acetaminophen
2. levothyroxine sodium
3. hydrocodone and acetaminophen
4. lisinopril
5. hydrocodone and acetaminophen
6. simvastatin
7. azithromycin
8. Proair HFA
9. Crestor
10. levothyroxine sodium
11. Synthroid
12. Nexium
13. atorvastatin
14. ibuprofen
15. trazodone HCl
16. metoprolol tartrate
17. azithromycin
18. warfarin
19. Cymbalta
20. fluticasone propionate
INDICATIONS
hydrocodone and acetaminophen, ibuprofen PAIN RELIEVERS
BRAND NAME: Co-Gesic, hycet, Lorcet, Lortab, Margesic, Maxidone, Norco, Stagesic, Vicodin, Xodol,
Zamicet, Zydone
GENERIC NAME: HYCD/APAP (hydrocodone with acetaminophen)
THERAPEUTIC CATEGORY: opioid analgesic
USE: post-operative pain control
ORAL COMPLICATIONS: xerostomia (rare)
DRUG INTERACTIONS: Concurrent use of hydrocodone with MAO inhibitors (Nardil, Parnate,
Marplan), tricyclic antidepressants (Elavil) and general anesthetics potentiates the effects of the
hydrocodone, and increases the risk for toxicity. Dextroamphetamine enhances the analgesic effect of the
hydrocodone. Additive CNS effects may occur when taking hydrocodone with other narcotics,
antipsychotics, antianxiety agents, general anesthetics and other CNS depressants (eg. alcohol).
Phenothiazines (eg. Thorazine) may decrease the analgesic effect of hydrocodone. Acetaminophen taken
with alcohol, barbituates or carbamazepine (Tegretol) increases the risk for liver toxicity. Chronic use of
acetaminophen may significantly enhance the anticoagulation effects of warfarin (Coumadin).

BRAND NAME: Caldolor, Ibu, Motrin
GENERIC NAME: ibuprofen
THERAPEUTIC CATEGORY: NSAID
USE: management of mild to moderate pain; inflammatory diseases and rheumatoid disorders, fever,
dysmenorrhea
ORAL COMPLICATIONS: none
DRUG INTERACTIONS: Ibuprofen and other non-selective NSAIDS can interfere with the antiplatelet
and cardioprotective effects of aspirin: follow appropriate timing of dosing. Avoid use in aspirin-allergic
patients. Ibuprofen may increase the levels of anticoagulants, antiplatelet drugs, bisphosphonates,
cyclosporine, digoxin, haloperidol, lithium, methotrexate, NSAIDS, potassium-sparing diuretics,
quinolone antibiotics, salicylates, thrombolytic agents, vancomycin and vitamin K antagonists. Levels of
ibuprofen may be increased by ACE inhibitors, angiotensin II receptor blockers, antidepressants
(tricyclic, teriary amine), systemic corticosteroids, glucosamine, herbs that have anticoagulant or
antiplatelet properties, NSAIDS, probenecid, SSRIs, serotonin/norepinephrine reuptake inhibitors.
Ibuprofen may decrease the levels of ACE inhibitors, angiotensin II receptor blockers, antiplatelet agents,
beta blockers, loop diuretics, potassium-sparing diuretics, salicylates and thiazide diuretics. Levels of
ibuprofen may be decreased by bile acid sequestrants, NSAIDS and salicylates. Avoid alcohol.
HYPERCHOLESTEROLEMIA

BRAND NAME: Zocor
GENERIC NAME: simvastatin
THERAPEUTIC CATEGORY: HMG-CoA reductase inhibitor
USE: hypercholesterolemia
ORAL COMPLICATIONS: taste alteration
DRUG INTERACTIONS: The risk for myopathy/rhabdomyolysis is increased with concurrent use of the
macrolide antibiotics clarithromycin and erythromycin, and the azole antifungal agents fluconazole,
itraconazole and ketoconazole. Risk for rhabdomyolysis also may be increased with concurrent use of
other lipid lowering agents, cyclosporoine, certain calcium channel blockers and protease inhibitors. The
anticoagulant effect of warfarin may be increased by simvastatin.


BRAND NAME: Crestor
GENERIC NAME: rosuvastatin calcium
THERAPEUTIC CATEGORY: HMG-CoA reductase inhibitor
USE: used with dietary therapy for hyperlipidemias to reduce elevated total cholesterol, LDL-C,
apolipoprotein B and triglycerides in patients with hypercholesterolemia and for treatment of familial
hypercholesterolemia
ORAL COMPLICATIONS: none
DRUG INTERACTIONS: The anticoagulant effects of warfarin may be increased by rosuvastatin:
monitor carefully. Rosuvastatin increases the serum concentrations of the hormonal contraceptives
ethinyl estradiol and norgestrel. Concurrent administration of other cholesterol lowering medications
(gemfibrozil, clofibrate, fenofibrate or niacin) may increase the risk for myopathy and rhabdomyolysis.
Metal containing antacids may decrease the plasma concentratins of rosuvastatin: administer antacids at
least 2 hours after dosing. Bile acid sequestrants may reduce the absorption of rosuvastatin.

HYPERTENSION
BRAND NAME: Toprol-XL
GENERIC NAME: metoprolol succinate
THERAPEUTIC CATEGORY: cardioselective beta blocker
USE: hypertension, angina, prevention of MI, atrial fibrillation; investigational for ventricular
arrhythmias, migraines, essential tremors, aggressive behavior
ORAL COMPLICATIONS: xerostomia
DRUG INTERACTIONS: Metoprolol may increase the effects of other drugs that slow AV conduction,
alpha-blockers and alpha-adrenergic stimulants (eg. epinephrine). Epinephrine is safe to use in patients
taking cardioselective beta blockers (lowest dose, least concentration). NSAIDS (ibuprofen,
indomethacin) used for greater than 3 weeks can decrease the antihypertensive effects of the drug. The
effects of beta blockers are decreased with aluminum salts, calcium salts, barbituates, bile acid
sequestrants (cholesterol-lowering drugs), NSAIDS, penicillins, rifampin and salicylates. Beta blockers
may decrease the effects of sulfonylureas (oral hypoglycemics), and may slow the metabolism of
lidocaine. Increased hypotension and bradycardia may be observed with concurrent use of inhaled
anesthetics and fentanyl derivatives.

ADVERSE THROMBOEMBOLIC EVENTS

BRAND NAME: Coumadin, Jantoven
GENERIC NAME: warfarin
THERAPEUTIC CATEGORY: anticoagulant, Vitamin K antagonist
USE: prophylaxis and treatment of thromboembolic disorders and embolic complications arising from
atrial fibrillation or cardiac valve replacement; risk reduction of systemic embolism after MI
ORAL COMPLICATIONS: gingival bleeding, aphthous ulcers, taste disturbance, vomiting
DRUG INTERACTIONS: **many drug interactions: always check for compatibility prior to prescribing.
Select interactions: acetaminophen, androgens, antiplatelet agents, cephalosporins, corticosteroids
(systemic), fluconazole, HMG-CoA Reductase Inhibitors (statins), itraconazole, ketoconazole, macrolide
antibiotics, metronidazole, NSAIDS (nonselective and COX-2 inhibitors), quinolone antibiotics,
salicylates, tricyclic antidepressants, numerous herbs


ENDOCRINE DISORDERS
BRAND NAME: Synthroid
GENERIC NAME: levothyroxine
THERAPEUTIC CATEGORY: hormone
USE: hypothyroidism
ORAL COMPLICATIONS: none
DRUG INTERACTIONS: Levothyroxine increases the effects of oral anticoagulants (Coumadin),
causing an increased risk of bleeding. When taken together, toxicity may occur for both levothyroxine
and tricyclic antidepressants (Elavil). Antacids containing aluminum and magnesium, iron, bile acid
sequestrants (colestipol, cholestyramine), and the ulcer medication sucralfate (Carafate) decrease the
absorption of levothyroxine. Certain seizure medications (phenytoin, phenobarbitol and carbamazepine)
and the TB medication rifampin (Rifadin) decrease levothyroxine levels. Levothyroxine may decrease
the effect of oral sulfonylureas.

ANTIBIOTICS

BRAND NAME: AzaSite, Zithromax, Zmax
GENERIC NAME: azithromycin
THERAPEUTIC CATEGORY: macrolide antibiotic
USE: orofacial and respiratory tract infections; middle ear infections, pharyngitis, strep throat, tonsillitis,
pneumonia; premedication
ORAL COMPLICATIONS: none
DRUG INTERACTIONS: Antacids containing aluminum or magnesium (Maalox, Mylanta) should not
be taken with azithromycin, as antacids decrease serum levels of the drug. Two hours should lapse prior
to taking azithromycin following the use of an antacid. As with erythromycin, azithromycin interacts
with many drugs, and may increase the levels of some antihistamines (Hismanal), cyclosporine
(Sandimmune), carbamazepine (Tegretol), digoxin (Lanoxin), phenytoin (Dilantin), triazolam (Halcion),
warfarin (Coumadin) and antiasthmatic drugs containing theophylline. Concomitant use of the macrolide
antibiotics with the HMG Co-A reductase inhibitors increases the risk for rhabdomyolysis. Antibiotics
decrease the effectiveness of oral contraceptives.

ANTIDEPRESSANTS

BRAND NAME: Cymbalta
GENERIC NAME: duloxetine
THERAPEUTIC CATEGORY: serotonin norepinephrine reuptake inhibitor
USE: major depressive disorder, generalized anxiety disorder, diabetic peripheral neuropathic pain,
fibromyalgia, chronic musculoskeletal pain
ORAL COMPLICATIONS: xerostomia, taste alteration
DRUG INTERACTIONS: administer vasoconstrictor with caution due to increase in norepinephrine in
the CNS: monitor vital signs; concurrent use of NSAIDS may increase risk for bleeding

BRAND NAME: Oleptro
GENERIC NAME: trazodone
THERAPEUTIC CATEGORY: serotonin reuptake inhibitor/antagonist
USE: major depressive disorder
ORAL COMPLICATIONS: xerostomia, taste alteration
DRUG INTERACTIONS: Sedative effects may be increased with alcohol and other CNS depressants;
avoid concurrent use with dabigatran, MAO inhibitors, saquinavir, and methylene blue (used to treat
methemoglobinemia and UTI). Trazodone may increase the levels of antipsychotic agents, phenytoin,
serotonin modulators. Levels of trazodone may be increased by antipsychotics, SSRIs, protease
inhibitors, venlafaxine. Trazodone may decrease the level of warfarin.
GERD OR HYPERSECRETORY DISEASE

BRAND NAME: Nexium
GENERIC NAME: esomeprazole
THERAPEUTIC CATEGORY: proton pump inhibitor
USE: short-term treatment of erosive esophagitis; symptomatic gastroesophageal reflux disease (GERD)
ORAL COMPLICATIONS: xerostomia
DRUG INTERACTIONS: Esomeprazole may increase the levels of carbamazepine, statin drugs, and
some benzodiazepines (diazepam, midazolam, triazolam). Drugs in this class may decrease the
absorption of antiretroviral medications, iron, and systemic antifungal medications (itraconazole,
ketoconazole). Esomeprazole may decrease the levels of phenytoin. Drug absorption is significantly
decreased (43%-53%) when taken with food; take at least 1 hour before meals.

RESPIRATORY DISEASE

BRAND NAME: Inhalation: Flovent Diskus, Flovent HFA; Nasal: Flonase, Veramyst
GENERIC NAME: fluticasone propionate
THERAPEUTIC CATEGORY: corticosteroid
USE: asthma, seasonal and perennial allergic rhinitis
ORAL COMPLICATIONS: oral fungal infections (inhalation); oral ulcerations, oral erythema and rashes,
oral discomfort and pain, mouth and tongue disorders, caries
DRUG INTERACTIONS: Avoid use with some immunosuppressants (natalizumab, pimecrolimus,
tacrolimus); fluticasone (inhaled) may increase the levels of amphotericin B, loop and thiazide diuretics;
levels of fluticasone may be altered by immunosuppressants; fluticasone may decrease the levels of
antidiabetic agents; vaccines (inactivated); levels of fluticasone may be decreased by Echinacea; rare
cases of anaphylaxis in patients with severe milk protein allergy who use Flovent Diskus (contains
lactose).

BRAND NAME: ProAir HFA
GENERIC NAME: albuterol
THERAPEUTIC CATEGORY: beta 2-adrenergic agonist
USE: asthma, chronic obstructive pulmonary disorder (COPD)
ORAL COMPLICATIONS: xerostomia, altered taste, vomiting, tooth discoloration
DRUG INTERACTIONS: Increased toxicity (cardiovascular effects) is noted when albuterol is
used with any of the following drugs: MAO inhibitors (Marplan, Nardil, Parnate), tricyclic
antidepressants (Elavil), sympathomimetic agents (amphetamines, dopamine) and inhaled
anesthetics(malignant arrhythmias). The effect of albuterol is decreased when used with
nonselective beta blockers. When used with inhaled ipratropium (Atrovent), an increase in the
duration of bronchodilation may occur.
REFERENCES FOR TOP 20 MEDICATIONS

Top 200 Drugs of 2012. Source: Pharmacy Times. Available at:

Physicians’ Desk Reference, ed. 66. Montvale, Medical Economics Co, Inc., 2012.
Mycek MJ, Harvey RA, Champe PC: Lippincott’s Illustrated Reviews: Pharmacology. ed. 3.
Philadelphia, Lippincott-Raven, 2006.
Wynn RL, Meiller TF, Crossley HL. Drug Information Handbook in Dentistry. 18th ed. Hudson, Lexi-
Comp Inc., 2012.
Gage TW, Pickett FA. Mosby’s Dental Drug Reference. 7th ed. St. Louis, Mosby, Inc., 2005.
Pickett FA, Terezhalmy GT. Dental Drug Reference with Clinical Implications. 2nd ed. Baltimore,
Lippincott Williams & Wilkens, 2008.

FDA WATCHES AND WARNINGS
varenicline (Chantix)
FDA Safety Alert and Public Health Advisory Statement Patients should be provided with a medication guide highlighting neuropsychiatric symptoms receiving this medication Angioedema, serious skin reactions, visual impairment, accidental injury July 2011 – relabeling changes due to cardiovascular concerns; FDA is requiring manufacturer to conduct meta-analysis of clinical trials to examine risks:
azithromycin, clarithromycin
May be associated with liver failure azithromycin and risk for fatal cardiac arrhythmia
ketoconazole (Nizoral)
FDA limits use due to potential for liver injury, adrenal insufficiency, serious drug interactions *no longer indicated for Candida infections (July 26, 2013)
tramadol (Ultram, Ultracet)
FDA safety labeling revision Potential risk for potentially life-threatening serotonin syndrome Serotonin syndrome may occur with use of tramadol alone or with concurrent use of SSRIs, tricyclic antidepressants, MAOIs Adverse events may occur at recommended tramadol dose tramadol is indicated for moderate to moderately severe pain in adults for short-term use (≤5 days) for acute pain AGENTS RELATED TO LOCAL ANESTHESIA
Local Anesthetic Induction Agent Onset® by Onpharma
Sodium bicarbonate, injection, 8.4% Indications: hastens the onset of analgesia reduces injection pain by adjusting lidocaine with epinephrine anesthetic solution to a more physiologic pH immediately prior to injection
Local Anesthetic Reversal Agent OraVerse® by Septodont
Phentolamine mesylate is a vasodilator (alpha adrenergic antagonist) used in medical indications since 1952 OraVerse™ is indicated for reversal of soft-tissue anesthesia, i.e., anesthesia of the lip and tongue, and the associated functional deficits resulting from an intraoral submucosal injection of a local anesthetic containing a vasoconstrictor OraVerse is not recommended for use in children less than 6 years of age or weighing less than 15 kg (33 lbs) There are no contraindications with OraVerse MANAGEMENT OF ORAL SIDE EFFECTS CAUSED BY MEDICATIONS

FLUORIDE THERAPY

For caries control:

Prescription fluorides for supplemental home use:
Clinpro 5000 Anti-Cavity Toothpaste (3M ESPE), Control Rx (Discus Dental), Fluoridex Daily Defense Dentifrice and Gel (Discus Dental), NUPRO NuSolutions Toothpaste (Dentsply), Oral B Neutracare (P&G), PreviDent 5000 Booster toothpaste, PreviDent Gel, PreviDent 5000 Plus (Colgate), ProDenRx Dentifrice and Gel (Zila), Topex Take Home Care (Sultan Healthcare) CaviRinse (3M ESPE), NaFrinse (Medical Products Laboratory), Oral B Fluorinse (P&G), PreviDent Dental Rinse (Colgate), ProDenRx Rinse (Zila) Fluoridex Daily Defense Sensitivity Relief (Discus Dental); Gel-Kam Oral Rinse (Colgate), Kid Kare Plus 0.4% Stannous Fluoride Brush-on Dentifrice, Kids Kare 0.4% Stannous Fluoride Brush-on Gel (Zila), ProDenRx 0.4% Stannous Fluoride Brush-on Gel (Zila), Topex Take Home Care (Sultan Healthcare) PerioMed (3M ESPE), Fluoridex Daily Renewal (Discus

Over-the-counter supplemental fluorides for home use:
Reach Act, Fluorigard, NaF rinse acidulated, NaF rinse neutral Phos-Flur (Colgate); OrthoWash (3M ESPE) acidulated phosphate rinse 0.4% stannous fluoride gel 1000 ppm Gel-Kam Treatment Gel (Colgate), Just For Kids (3M ESPE), Omni Gel (3M ESPE), Oral B Stop (P&G) Listerine Total Care, Listerine Smart Rinse (J&J)
Fluoride Varnishes: 22,600 PPM sodium fluoride
FluoroDose (Centrix) Fluoridex Lasting Defense (Discus Dental) Prevident (Colgate) Profluorid Varnish (VOCO) Vanish (Omni/3M EPSE) VarnishAmerica with xylitol (Medical Products Laboratories) Vella with xylitol (Preventech) Waterpik UltraThin (Teledyne)
SALIVARY REPLACEMENT THERAPY

1. OTC Artificial Saliva Preparations:
Entertainer’s Secret® (KLI Corp.) Moi-Stir® (Kingswood Laboratories, Inc.) Mouthkote® (Parnell Pharmaceuticals) Salivart® (Gebauer Company) Oral Balance® spray or gel (GlaxoSmithKline) Orajel® Dry Mouth Relief or Moisturizing Gel (Del Pharmaceuticals, Inc.) Oasis® rinse (Oasis Consumer Healthcare) GC Dry Mouth gel (GC America) Salese lozenges (Nuvora) -carboxymethylcellulose = gives feeling of viscosity -relief while product is in contact with the tissues; convenience -some contain preservatives: parabens (PABA) = allergy potential 2. Biotene product line (GlaxoSmithKline): toothpaste, oral gel, mouthrinse, chewing gum
-contain 3 key salivary enzymes found in natural saliva; sodium fluoride, xylitol
3. Orajel product line (Del Pharmaceuticals, Inc.): dry mouth moisturizing gel and spray
-18% glycerin; -sorbitol (gel); xylitol (spray) -thione antioxidant complex; sodium monofluorophosphate (0.18% w/v fluoride ion) -sugar-free; sorbitol, xylitol; no sodium lauryl sulfate 4. Oasis (Oasis Consumer Healthcare)
-“TriHydra” technology: hydrophilic polymers, xanthum gum, glycerine and carboxymethylcellulose; relieves symptoms for up to 2 hours
5. GC Dry Mouth Gel (GC America)
-alcohol free, sugar free, neutral pH, applied as needed 6. Salese (Nuvora)
-lozenge with water absorbing polymer plus xylitol; raises pH; Dentiva: antimicrobial
7. Two prescription drugs now available to stimulate salivary flow:

Salagen (5 mg pilocarpine hydrochloride)
-cholinergic agonist that stimulates muscarinic acetylcholine receptors in the salivary glands to
increase serous salivary flow.
-need to take the drug for a minimum of 90 days to see optimum effects
-contraindicated if known hypersensitivity to the drug, uncontrolled asthma or narrow-angle
glaucoma
-drug interactions associated with pilocarpine include anticholinergic medications (eg.
antiparkinsonion drugs, carbamazepine, digoxin, sedative antihistamines, tricyclic
antidepressants), cholinergic medications (eg. antiglaucoma drugs) and beta-adrenergic blocking
drugs
-indicated for radiation therapy patients and Sjogren’s syndrome
- dosage: for radiation therapy patients:
- 5 mg tid (15-30 mg per day); 12 weeks of therapy - dosage: for Sjogren’s patients:
- 5 mg qid; efficacy has been established after 6 weeks of use Evoxac (cevimeline)
-cholinergic agonist used to treat xerostomia in patients with Sjogren’s syndrome
- dosage: 30 mg tid
-contraindications: hypersensitivity to drug or any of its components, uncontrolled
asthma, narrow-angle glaucoma, acute iritis, conditions where miosis is undesirable
-use with caution in patients with CV disease, asthma, COPD, decreased visual acuity, the
elderly, or in those with kidney problems

ANTIMICROBIALS
-an important adjunct in managing the oral complications of xerostomia
-reduce plaque formation, and to prevent or reduce the severity of gingivitis
-OTC and prescription antimicrobials available on the market from which to choose -3 FDA and ADA approved antimicrobials: chlorhexidine, Listerine® and triclosan
(Colgate® Total)
- Other agents available as mouthrinses exhibit antibacterial properties, but do not
-stannous fluoride = antibacterial. carioprotective and desensitizing effects
-cetylpyridinium chloride = rupture bacterial cell walls and alter cytoplasmic
contents; bind strongly to plaque and tooth surfaces (Cepacol®, Scope®,
Advanced Formula Viadent®; alcohol free: Crest® Pro Health Rinse, BreathRx)
-Crest Pro Health Rinse with CPC has data to support 12 hour substantivity =
vehicle improves bioavailability
-oxygenating agents = damage bacteria by altering cell membrane permeability
-Natural Dentist® Health Gums Moisturizing Antigingivitis Mouthrinse
-germ kill of 40 oral pathogens, including Strep mutans and some red complex -comparable to Listerine® in terms of pathogen reduction -4 published clinical trials and MIC laboratory data to support efficacy -Triclosan (Colgate® Total toothpaste)
-antimicrobial agent in dentifrice form = decreases plaque viability -both antimicrobial and anti-inflammatory properties -unique technology of delivery mode: PVM/MA copolymer = GANTREZ -copolymer allows binding to surfaces with slow release; promotes adhesion/uptake of triclosan on enamel, plaque and soft tissue -triclosan: broad spectrum, substantive to 12 hours -over 85 clinical trials to support safety and efficacy of Colgate® Total -anti-inflammatory effect: dampens stimulation of the production of IL1- beta and TNF alpha = inflammatory mediators (cytokines) that destroy tissue and bone = local host modulation -Crest® Pro Health dentifrice
-stannous fluoride multi-care dentifrice -older formulations: adverse taste and staining effects; instable in aqueous solutions -0.454% stabilized stannous fluoride with sodium hexametaphosphate -sodium hexametaphosphate = pyrophosphonate (anti-calculus/anti- -polymer of repeated pyrophosphate subunits -stronger affinity to calcium hydroxyapatite in enamel and dentin -greater prevention of crystallization at enamel surface (calculus prevention) and adsorption of stains from chromogens (staining) - silica-based low-water dentifrice to reduce hydrolysis of sodium hexametaphosphate and to maintain effective pyrophosphate levels Important take home messages with antimicrobials:

- chlorhexidine and CPC are cations: drug reactions with SLS and fluoride = wait 30 minutes
after brushing or vigorously remove all toothpaste residue before rinsing
- chlorhexidine and Listerine have been shown to kill 7 species of Candida
- chlorhexidine and Listerine kill multiple species of Strep: Strep mutans
- chlorhexidine and Listerine have been shown to reduce incidence and severity of aphthous
ulcers
ANTIFUNGALS

fungal infections occur as a result of alterations in oral flora, immunosuppression and underlying systemic disease (diabetes, xerostomia, anemia, chemo, inhaled steroids) - opportunistic infections
- clinical presentation:
- pseudomembranous appearance (bright red with overlying white pseudomembrane); atrophic appearance (tongue); hyperkeratotic appearance (denture stomatitis); symptomatic geographic tongue; angular cheilitis -drug therapy includes topical and systemic medications depending upon the extent and severity
of the infection.
-azole antifungals are used to treat chronic, extensive mucocutaneous candidiasis
-polyenes are used to treat local candidiasis (topicals)
-antifungals are being used in combination with corticosteroids, such as nystatin and
triamcinolone, to treat both the fungal infection and the inflammation of angular cheilitis
- medications must be used for a minimum of 48 hours after the disappearance of clinical
signs and symptoms; re-evaluate condition 14 days after therapy has been completed
- efficacy of topical drugs is dependent upon contact with the lesions - some topical preparations contain sugar - may choose to prescribe vaginal preparation
- in addition to antifungals, consider chlorhexidine or essential oil mouthrinses
for long term prevention
- prescription antifungals for systemic use if patient is refractory to topicals: *cautions: liver function and multiple drug interactions
Topical Antifungal Medications:
apply thin coat to affected area (or inner surface of denture) 4-5 times per day disp: 70 troches; dissolve 1 troche in mouth 5 times per day until gone; leave any prosthesis out during treatment and soak prosthesis in nystatin liquid suspension overnight apply thin coat to affect areas (or to inner surface of denture) after apply locally to affected area 3-4 times per day for 10 days to 2 apply locally to affected area 4 times per day for 10 days to 3 weeks Topical nystatin:
- soak dentures in nystatin suspension overnight - nystatin ointment can be placed in denture and worn during day (like an adhesive)
Systemic Azole Antifungal Medications:
Fluconazole (Diflucan®) 100 mg tablets; Take 2 tablets on day 1, then 1 tablet daily for 14 days until
gone; *a shorter course may be adequate; extensive infection may require second course of treatment
ANTIVIRALS

- viral infections: acute onset of symptoms
- vesicular eruption of soft tissues
- rupture of vesicles leaves ulcerations - ulcerations are generally small in size - if left untreated, ulcerations coalesce to form large lesions
- primary infection can present as: gingivostomatitis, recurrent lip lesions (herpes labialis),
intraoral ulcers (recurrent intraoral herpes) that involve oral/perioral tissues
- primary infection is systemic that leads to acute gingivostomatitis involving multiple tissues:
buccal mucosa, lips, tongue, floor of mouth, gingiva
- management of viral infections is generally palliative (although acyclovir is now used for
prevention of primary infections)
- treatment of primary infections includes combination therapy:
- acyclovir
- topical anesthetic rinses (eg. Benadryl, Xylocaine viscous, OTC
benzocaine products )
- fluids, vitamins and mineral supplements and rest

Antiviral Medications for Herpes Simplex:
take 1 capsule 5 times per day for 10 days or 2 capsules 3 times per day for 10 days apply q 3 hours (6 times/day) for 7 days apply every 2 hours (lips and face only) for 4 days (1%)
Valtrex® 500 mg
2 grams twice daily for 1 day at prodrome (separate doses by 12 hours) apply locally as directed 5 times per day; start at prodrome and continue for 4 days; do not apply directly to inside of mouth or around eyes Viroxyn® (OTC)
alcohol/benzalkonium single dose applicator/vial; at prodrome, rub chloride medication into lesion until medication is gone (10 seconds)
ORAL ULCERATIONS (NON-VIRAL) AND PAIN CONTROL
-Recurrent Aphthous Stomatitis:
- patients with recurrent aphthous should be evaluated for iron, folic acid and/or vitamin B12 deficiency - severe recurrent aphthous may be treated with an oral suspension of - regular use of Listerine has been shown to reduce the frequency, duration and severity of lesions; chlorhexidine has been shown to reduce duration of lesions -localized ulcerations:
- OTC topical anesthetic agents containing benzocaine in protective preparations - Benzocaine and tetracaine (Viractin) are esther anesthetics; therefore, caution must be used when recommending these OTC products to clients with reported allergies to anesthetics or to PABA - Debacterol (sulfonated phenolics in aqueous solution) – therapeutic - dry ulcer, apply directly to lesion, keep in contact for 5-10 seconds; (larger lesions may need up to 2 minutes); rinse immediately, and expectorate with water -generalized oral pain:
- OTC agent such as Chloraseptic® spray - prescription mouthrinse Xylocaine ® 2% (viscous lidocaine) - Benadryl® elixir and Benylin® cough syrup -severe pain, such as that associated with mucositis:
- anesthetic agents may be mixed with OTC coating agents to provide lubrication and relief from pain - Benadryl® elixir added in equal amounts to Maalox®, Mylanta® or Kaopectate® - sucralfate (Carafate®), the prescription medication used to treat duodenal ulcers, may be prepared as a 1 gm/15 mL suspension for use in this population as well. (A pharmacist should be consulted to assist with the preparation of oral suspensions.)
-dry, cracked lips: topical water-based product; Oral Balance®

Topical prescription agents for aphthous lesions:
apply 4 times per day (after meals and at bedtime) until area heals lesions that do not respond to Kenalog in Orabase®) clobetasol propionate 0.05% apply small quantity with a cotton tip applicator to affected area 3-4 times daily apply small quantity with a cotton tip applicator to affected area 3-4 times daily Topical OTC agents for aphthous/pain control:
swish with 1 tsp for 2 min before each meal (can be used as a swish and swallow) sodium carboxymethylcellulose Tetracaine Hydrochloride 1%
REFERENCES
Wynn RL, Meiller TF, Crossley HL. Drug Information Handbook in Dentistry. 18th ed. Hudson, Lexi-
Comp Inc., 2012.
Pickett FA, Terezhalmy GT. Dental Drug Reference with Clinical Implications. 2nd ed. Baltimore,
Lippincott Williams & Wilkens, 2008.
Porter SR, Scully C, Hegarty AM. An update of the etiology and management of xerostomia. Oral Surg
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Source: http://www.vsds.org/_ah/editor/documents/14-Spolarich-Commonly_Prescribed_Meds-Handout.pdf