Clinical Dental Pharmacology E-Book
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- Sprache: Englisch
Clinical Dental Pharmacology A convenient and authoritative quick reference for drugs relevant to clinical dentistry Clinical Dental Pharmacology delivers an essential reference for dental practitioners seeking quick, easy access to current and accurate information about drugs used by dentists in clinical practice. The book covers common drugs prescribed by dental practitioners as well as systemic medications which may impact on provision of clinical dental care. A separate section on recognition and management common medical emergencies in dental practice is also included. Readers will find relevant material covering the indications, pharmacodynamics, pharmacokinetics, routes of administration, dosage, preparations, side effects, cautions, and contraindications of a host of relevant drugs. The text is accompanied by images designed to facilitate a visual understanding of key concepts and is organized by drug class, making information easy to find. It is an indispensable resource designed to avoid potentially serious complications arising from the combination of dental care and drugs. The readers are signposted to professional guidelines from a variety of online sources to facilitate access to evidence-based and reliable information on each topic covered in the book. Clinical Dental Pharmacology readers will also benefit from: * Comprehensive coverage of drugs used in clinical dental practice * Discussions of a variety of classes of drugs, including analgesics, anti-inflammatories, local anesthetics, antimicrobials, and topical agents * Online resources for each chapter to aid in patient education Clinical Dental Pharmacology is written by team of experienced clinical dental academics and is ideal for dental students and as a reference for practicing dental clinicians.
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Table of Contents
Cover
Table of Contents
Title Page
Copyright
Dedication
List of Contributors
Preface
Abbreviations
SECTION I: Medications for Pain Control
CHAPTER 1: Analgesics
1.1 INTRODUCTION
1.2 NON‐NARCOTIC ANALGESICS
1.3 COMMON NON‐STEROIDAL ANTI‐INFLAMMATORY AGENTS USED IN DENTISTRY
1.4 NARCOTIC ANALGESICS
RESOURCES
REFERENCES
CHAPTER 2: Anti‐Neuralgic Medications
2.1 INTRODUCTION
2.2 OROFACIAL NEURALGIAS
RESOURCES
REFERENCES
CHAPTER 3: Local Anaesthetics
3.1 INTRODUCTION
3.2 LOCAL ANAESTHETICS USED IN DENTISTRY
3.3 INJECTABLE LOCAL ANAESTHETICS
3.4 LOCAL ANAESTHETICS FOR TOPICAL (SURFACE) USE
3.5 DOSAGE LIMITS
3.6 SUMMARY
ACKNOWLEDGEMENTS
RESOURCES
REFERENCES
SECTION II: Antimicrobial Medications
CHAPTER 4: Use of Antibiotics in Dentoalveolar Infections
4.1 INTRODUCTION
4.2 COMMON ANTIBIOTICS USED IN DENTOALVEOLAR INFECTIONS
RESOURCES
REFERENCES
CHAPTER 5: Use of Antibiotics in Periodontitis
5.1 INTRODUCTION
5.2 ROLE OF SYSTEMIC ANTIBIOTICS IN PERIODONTAL DISEASE
5.3 ROLE OF LOCAL DELIVERY ANTIBIOTICS IN PERIODONTAL DISEASE
5.4 USE OF LOW DOSE (SUB‐ANTIMICROBIAL) ANTIMICROBIALS
5.5 NECROTISING PERIODONTAL DISEASES
5.6 SUMMARY
ACKNOWLEDGEMENTS
RESOURCES
REFERENCES
CHAPTER 6: Antibiotic Prophylaxis Against Infective Endocarditis in Dentistry
6.1 INTRODUCTION
6.2 INDICATIONS FOR ANTIBIOTIC PROPHYLAXIS
6.3 DENTAL PROCEDURES
6.4 ANTIBIOTIC REGIMENS
6.5 SUMMARY
RESOURCES
REFERENCES
CHAPTER 7: Antimicrobial Resistance
7.1 INTRODUCTION
7.2 COMMON DRIVERS OF ANTIBIOTIC RESISTANCE
7.3 MECHANISMS OF ANTIBIOTIC RESISTANCE
7.4 TACKLING ANTIBIOTIC RESISTANCE
7.5 SUMMARY
ACKNOWLEDGEMENTS
RESOURCES
REFERENCES
CHAPTER 8: Antiviral Medications
8.1 INTRODUCTION
8.2 TREATMENT PRINCIPLES OF HERPES VIRUS INFECTIONS
8.3 ANTIVIRAL AGENTS FOR HERPES VIRUS INFECTIONS
8.4 MISCELLANEOUS VIRAL INFECTIONS
RESOURCES
REFERENCES
CHAPTER 9: Antifungal Agents
9.1 INTRODUCTION
9.2 TREATMENT PRINCIPLES OF ORAL CANDIDIASIS
9.3 COMMON ANTIFUNGAL AGENTS
9.4 OTHER ORAL FUNGAL INFECTIONS
RESOURCES
REFERENCES
SECTION III: Miscellaneous Agents
CHAPTER 10: Oral Hygiene Agents: Toothpastes
10.1 INTRODUCTION
10.2 COMPOSITION OF TOOTHPASTES
10.3 FLUORIDATED TOOTHPASTES
10.4 SPECIAL FORMULATION TOOTHPASTES
10.5 SUMMARY
RESOURCES
REFERENCES
CHAPTER 11: Oral Hygiene Agents: Mouthwashes
11.1 INTRODUCTION
11.2 COMPOSITION OF MOUTHWASHES
11.3 FLUORIDE MOUTHWASHES
11.4 ANTIMICROBIAL MOUTHWASHES
11.5 SUMMARY
RESOURCES
REFERENCES
CHAPTER 12: Agents Used in the Management of Oral Ulceration
12.1 INTRODUCTION
12.2 DRUG‐ASSOCIATED ORAL ULCERS (DAOUS)
ACKNOWLEDGEMENTS
RESOURCES
REFERENCES
CHAPTER 13: Agents Used in the Management of Xerostomia
13.1 INTRODUCTION
13.2 MANAGEMENT OF XEROSTOMIA
13.3 SUMMARY
RESOURCES
REFERENCES
SECTION IV: Systemic Medications
CHAPTER 14: Oral Side Effects of Systemic Medications
14.1 INTRODUCTION
14.2 DRUG‐ASSOCIATED REACTIONS IN THE ORO‐FACIAL REGION
14.3 SUMMARY
14.4 SYSTEMIC MEDICATIONS ASSOCIATED WITH COMPLICATIONS FOLLOWING ORAL SURGICAL INTERVENTIONS
ACKNOWLEDGEMENTS
RESOURCES
REFERENCES
CHAPTER 15: Dental Management of Patients on Blood Thinners
15.1 INTRODUCTION
15.2 ANTIPLATELET AGENTS
15.3 ANTICOAGULANT AGENTS
15.4 DENTAL AND ORAL SURGICAL MANAGEMENT OF PATIENTS ON ANTIPLATELETS AND ANTICOAGULANTS
15.5 SUMMARY
RESOURCES
REFERENCES
CHAPTER 16: Medication‐Related Osteonecrosis of Jaws
16.1 INTRODUCTION
16.2 RISK ASSESSMENT
16.3 MANAGEMENT OF MRONJ
ACKNOWLEDGEMENTS
RESOURCES
REFERENCES
SECTION V: Medical Emergencies
CHAPTER 17: Management of Medical Emergencies
17.1 INTRODUCTION
17.2 PATIENT ASSESSMENT
17.3 VASOVAGAL SYNCOPE
17.4 ACUTE CHEST PAIN
17.5 CARDIAC ARREST
17.6 CHOKING AND ASPIRATION
17.7 ACUTE ASTHMA
17.8 HYPERVENTILATION
17.9 ANAPHYLAXIS
17.10 HYPOGLYCAEMIA
17.11 ADRENAL INSUFFICIENCY
17.12 EPILEPTIC SEIZURES
17.13 CEREBROVASCULAR ACCIDENT
ACKNOWLEDGEMENTS
RESOURCES
REFERENCES
APPENDIX A: Prescription Writing
APPENDIX B: Drug Prescriptions in Elderly Patients
APPENDIX C: Drug Prescriptions in Children
APPENDIX D: Drug Prescriptions During Pregnancy
APPENDIX E: Drug Prescriptions to Breastfeeding Mothers
APPENDIX F: Drug Prescriptions in Patients with Hepatic Disease
APPENDIX G: Drug Prescriptions in Patients with Renal Disease
Index
End User License Agreement
List of Tables
Chapter 2
Table 2.1 Differential Diagnosis of Orofacial Pain
Chapter 3
Table 3.1 Classification of Local Anaesthetics
Table 3.2 Properties of Commonly Used Local Anaesthetics in Dentistry
Table 3.3 Duration of Commonly Used Local Anaesthetics in Dentistry
Table 3.4 Maximum Dosage of Commonly Used Local Anaesthetics in Dentistry
Table 3.5 Local Anaesthetic Dose in Milligrams Per Dental Cartridge
Chapter 4
Table 4.1 Indications for Urgent Referral of Patients with Dentoalveolar Inf...
Table 4.2 Red and Amber Flags of Sepsis
Table 4.3 Classification of Cephalosporins
Chapter 6
Table 6.1 Conditions Associated with High Risk of Developing Infective Endoc...
Table 6.2 Classification of Dental Procedures
3
Table 6.3 Antibiotic Regimens for a Dental Procedure Regimen, United Kingdom...
Table 6.4 Antibiotic Regimens for a Dental Procedure, United States: Single ...
Chapter 7
Table 7.1 Bacterial Mechanisms of Developing Resistance to Antibiotics
Chapter 9
Table 9.1 Predisposing Factors for Oral Candidiasis
Chapter 10
Table 10.1 Recommendations on Fluoridated Toothpastes for Individuals at low...
Table 10.2 Recommendations on Fluoridated Toothpastes for Individuals at Hig...
Table 10.3 Active Ingredients in Desensitising Toothpastes
Table 10.4 Mode of Action of Whitening Toothpastes
Chapter 11
Table 11.1 Common Regimens for Fluoride‐Based Mouthwashes
Chapter 12
Table 12.1 Differential Diagnosis of Oral Ulceration
Table 12.2 Drugs Associated with Oral Ulcers
Chapter 13
Table 13.1 Causes of Xerostomia
Chapter 15
Table 15.1 Common Oral Antiplatelet Agents
Table 15.2 Common Oral Anticoagulants
Table 15.3 Oral Anticoagulants: Interactions and Contra‐Indications
Chapter 16
Table 16.1 Medications Associated with Osteonecrosis of Jaws
Table 16.2 Risk Factors for MRONJ
Table 16.3 MRONJ Staging and Treatment
Chapter 17
Table 17.1 ABCDE Assessment of Patients Experiencing Medical Emergencies
Table 17.2 Differential Diagnosis of Acute Chest Pain
Table 17.3 A Comparison of Clinical Presentation of Hypoglycaemia and Hyperg...
Table 17.4 Other Causes of Hypoglycaemia
Appendix D
Table D.1 Drug Prescription During Pregnancy
Appendix E
Table E.1 Drug Prescription to Breastfeeding Mothers
Appendix F
Table F.1 Drug Prescription in Patients with Hepatic Disease
Appendix G
Table G.1 Drug Prescription in Patients with Renal Disease
List of Illustrations
Chapter 1
Figure 1.1 Mechanism of action of non‐steroidal anti‐inflammatory drugs.
Chapter 3
Figure 3.1 Ischaemic necrosis of the left palatal mucosa following injection...
Chapter 5
Figure 5.1 Application of Dentomycin
®
to periodontal pocket
Figure 5.2 Presentation of necrotising periodontal disease
Figure 5.3 Necrotising periodontitis case shown in Figure 5.2 after treatmen...
Figure 5.4 Oral soft tissue destruction in Noma
Chapter 7
Figure 7.1 Schematic illustration of common mechanisms responsible for antim...
Chapter 8
Figure 8.1 Herpes zoster infection of the face in the distribution of the ri...
Chapter 9
Figure 9.1 An elderly lady with bilateral angular cheilitis (a). Complete re...
Chapter 12
Figure 12.1 A large nodulo‐ulcerative growth on the right lateral border of ...
Figure 12.2 Erythema and ulceration on the right buccal mucosa in a patient ...
Chapter 14
Figure 14.1 Generalised gingival enlargement in a patient taking cyclosporin...
Figure 14.2 Bilateral severe lichenoid reaction in a patient taking amlodipi...
Figure 14.3 Hairy tongue in a patient on minocycline
Chapter 16
Figure 16.1 Ulceration and bone necrosis following extraction of lower left ...
Chapter 17
Figure 17.1 Pathophysiology of vasovagal syncope
Figure 17.2 Chair positioning to restore cerebral circulation in syncope
Figure 17.3 Head tilt, chin lift (a) and jaw thrust (b) manoeuvres to open t...
Figure 17.4 Oropharyngeal airways of different sizes (a). Placement of an or...
Figure 17.5 Checking for breathing
Figure 17.6 Identifying the correct spot for chest compressions
Figure 17.7 Position for chest compressions
Figure 17.8 Oxygen mask
Figure 17.9 Bag‐valve mask ventilation
Figure 17.10 Automated external defibrillator
Figure 17.11 Adult Basic Life Support Algorithm
Figure 17.12 Steps for placing a patient into a recovery position. (a) Place...
Figure 17.13 Algorithm for management of choking in adults
Figure 17.14 Back blows to clear respiratory obstruction in adults
Figure 17.15 Abdominal thrusts to clear respiratory obstruction in adults
Figure 17.16 Back blows to clear respiratory obstruction in infants and chil...
Figure 17.17 Chest thrusts to clear respiratory obstruction in infants
Guide
Cover
Table of Contents
Title Page
Copyright
Dedication
List of Contributors
Preface
Abbreviations
Begin Reading
APPENDIX A Prescription Writing
APPENDIX B Drug Prescriptions in Elderly Patients
APPENDIX C Drug Prescriptions in Children
APPENDIX D Drug Prescriptions During Pregnancy
APPENDIX E Drug Prescriptions to Breastfeeding Mothers
APPENDIX F Drug Prescriptions in Patients with Hepatic Disease
APPENDIX G Drug Prescriptions in Patients with Renal Disease
Index
End User License Agreement
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Clinical Dental Pharmacology
Edited byKamran AliQatar UniversityQU HealthCollege of Dental MedicineDohaQatar
This edition first published 2024
© 2024 John Wiley & Sons Ltd
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The right of Kamran Ali to be identified as the author of the editorial material in this work has been asserted in accordance with law.
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Limit of Liability/Disclaimer of Warranty
The contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting scientific method, diagnosis, or treatment by physicians for any particular patient. In view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and for added warnings and precautions. While the publisher and authors have used their best efforts in preparing this work, they make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of merchantability or fitness for a particular purpose. No warranty may be created or extended by sales representatives, written sales materials or promotional statements for this work. The fact that an organization, website, or product is referred to in this work as a citation and/or potential source of further information does not mean that the publisher and authors endorse the information or services the organization, website, or product may provide or recommendations it may make. This work is sold with the understanding that the publisher is not engaged in rendering professional services. The advice and strategies contained herein may not be suitable for your situation. You should consult with a specialist where appropriate. Further, readers should be aware that websites listed in this work may have changed or disappeared between when this work was written and when it is read. Neither the publisher nor authors shall be liable for any loss of profit or any other commercial damages, including but not limited to special, incidental, consequential, or other damages.
Library of Congress Cataloging‐in‐Publication Data
Names: Ali, Kamran, editor.
Title: Clinical dental pharmacology / edited by Kamran Ali.
Description: Hoboken, NJ : Wiley‐Blackwell, 2024. | Includes index.
Identifiers: LCCN 2024009202 (print) | LCCN 2024009203 (ebook) | ISBN
9781119984931 (paperback) | ISBN 9781119984948 (Adobe PDF) | ISBN
9781119984955 (epub)
Subjects: MESH: Pharmaceutical Preparations, Dental–pharmacology | Tooth
Diseases–drug therapy | Pharmacology, Clinical
Classification: LCC RK305 (print) | LCC RK305 (ebook) | NLM QV 50 | DDC
617.6/3061–dc23/eng/20240314
LC record available at https://lccn.loc.gov/2024009202
LC ebook record available at https://lccn.loc.gov/2024009203
Cover Design: Wiley
Cover Images: Courtesy of Kamran Ali
My late parents for their relentless sacrifices and dedication; their loving memories continue to inspire me.
My dear wife, Mahwish, for her unwavering support, patience, and understanding.
My beloved sons, Asad and Turab, the greatest blessings in my life.
List of Contributors
Kamran Ali
Qatar University
QU Health
College of Dental Medicine
Doha
Qatar
Sadeq Ali Al‐Maweri
Qatar University
QU Health
College of Dental Medicine
Doha
Qatar
Gail V.A. Douglas
School of Dentistry
University of Leeds
Leeds
UK
Manal Matoug‐Elwerfelli
Qatar University
QU Health
College of Dental Medicine
Doha
Qatar
Ewen McColl
Plymouth University
Faculty of Health (Medicine, Dentistry, and Human Sciences)
Department of Clinical Dentistry
Plymouth
UK
Mahwish Raja
Qatar University
QU Health
College of Dental Medicine
Doha
Qatar
Susu M. Zughaier
Qatar University
QU Health
College of Dental Medicine
Doha
Qatar
Preface
It is a pleasure to share this book entitled Clinical Dental Pharmacology. Although there a large number of resources on pharmacology, there has been a long‐standing need for a comprehensive text to support decision‐making regarding drug prescriptions in clinical dental practice. I am positive that the book will address this gap and serve as an authentic resource for dental professionals and students alike.
The book covers common drugs prescribed by dental practitioners as well as systemic medications which may impact on provision of clinical dental care. A separate section on recognition and management common medical emergencies in dental practice is also included. Pharmacology is a complex subject and a plethora of new information on drugs emerges regularly. Dental professionals may find it difficult to keep pace with latest research and how different drugs may impact on their dental practice. The readers are signposted to professional guidelines from a variety of online sources to facilitate access to evidence‐based and reliable information on each topic covered in the book. The readers are advised to consult the guidelines directly from the relevant websites to read the most updated version of the guidelines. Each chapter also includes online resources which can be used for patient education.
The book is aimed at a global audience and covers a wide range of topics. Dental professionals are reminded to consider their scope of practice in the light of national legislation and professional regulations and guidelines applicable to their geographic location. All health professionals must always act in the best interests of the patients and if management of a patient is beyond the expertise of a dental professional, it is best to seek advice from an appropriate colleague or specialist.
I am grateful to all authors for their excellent contributions.
KAMRANALI
Qatar UniversityQU Health College of Dental MedicineDoha, Qatar08 December 2023
Abbreviations
A&E
accident and emergency
ACE
angiotensin‐converting enzyme
AHA
American Heart Association
b.i.d.
bis in die – twice daily
b.i.d.
quarter in die – four times daily
BLS
basic life support
BNF
British National Formulary
BP
blood pressure
BT
bleeding time
COPD
chronic obstructive pulmonary disease
CPR
cardiopulmonary resuscitation
CVA
cerebrovascular accident
DM
diabetes mellitus
DNF
dental national formulary
EU
European Union
−
F
fluoride ion
HHV
human herpes virus
HR
heart rate
IAN
inferior alveolar nerve
IDN
inferior dental nerve
IHD
ischaemic heart disease
IM
intramuscular
INR
international normalised ratio
ION
infra orbital nerve
IV
intravenous
LA
local anaesthesia
LN
lingual nerve
LOC
loss of consciousness
Mane
in the morning
MAO
mono amino oxidase
mg
milli gram
MI
myocardial infarction
mL
milli litre
Nocte
at night
°C
degree Celsius
OD
once daily
°F
degree Fahrenheit
OSA
obstructive sleep apnoea
OTC
over the counter
PO
per oral (by mouth)
ppm
parts per million
PT
prothrombin time
q.i.d.
quater in die – four times daily
s.c.
subcutaneous
Stat
statim – immediately
t.i.d.
ter in die – three times daily
TCA
tricyclic antidepressant
tsp
teaspoon
U.S.P.
United States pharmacopeia
w
with
w/o
without
SECTION IMedications for Pain Control
CHAPTER 1Analgesics
Kamran Ali
Qatar University, QU Health, College of Dental Medicine, Doha, Qatar
1.1 INTRODUCTION
One of the commonest presenting complaint of patients in dentistry is pain, and dentists routinely advise/prescribe analgesics. However, the main purpose of analgesics is to provide symptomatic relief before definitive treatment and minimise pain following operative interventions. Pain control during operative dental procedures is usually accomplished with administration of local anaesthesia (Chapter 3). Appropriate management of dental and orofacial pain should address the cause of pain using a comprehensive clinical assessment and relevant investigations such as radiographs. For example, patients presenting with features of pulpitis may benefit from analgesics to achieve pain relief, and definitive pain relief is best obtained through operative management of the inflamed pulp. Similarly, the use of analgesics to manage pain related to a peri‐radicular abscess can only provide a partial and temporary relief, at best. Definitive management of the abscess would require drainage of the abscess through root canal access opening or tooth extraction, as appropriate.
Some of the key principles which need to be observed when prescribing analgesics in dentistry are summarised as follows:
Undertake a comprehensive clinical assessment
Before advising or prescribing an analgesic, it is important to assess the source of pain along with its character, severity, site, frequency, aggravating and relieving factors to aid an accurate diagnosis.
Choose an appropriate analgesic
The choice of analgesic will depend on the cause and severity of pain as well as the patient's medical history and any contraindications. All medications have potential risks and benefits, and the choice of an analgesic should take into account the patient's systemic health, and any potential drug interactions of the proposed analgesics with any medications the patient may be taking.
Determine route of administration
In most cases, analgesics used for the management of pain in dental patients are administered orally. However, for pain associated with certain chronic conditions, such as myofascial pain and internal derangement of temporomandibular joint, topical application may be appropriate to minimise the systemic side effects associated with long‐term use of oral analgesics. Parenteral administration of analgesics for acute dental pain is usually not undertaken in general dental practice settings. Nevertheless, local anaesthetic administration can be used for immediate management of severe acute pain.
Determine the dose and duration of analgesics cover
Analgesics should be used at the lowest effective dose for the shortest duration necessary. This can help reduce the risk of side effects and addiction and minimise the cost. In most cases analgesics used for the management of acute dental pain are administered orally for few days until definitive management of the underlying problem. Similarly post‐operative pain following invasive dental procedures requires analgesics for up to a week. However, pain associated with certain chronic conditions such as temporomandibular joint disorders (e.g., myofascial pain and internal derangement) and trigeminal neuralgia may require long‐term analgesics. As mentioned before, topical application of analgesics may be considered if appropriate to minimise the systemic side effects associated with long‐term use of analgesics.
Consider the cost of analgesics
Many analgesics used in dentistry are available over the counter, and it may be much cheaper for the patients to purchase these themselves on a dentist's advice. Dispensing analgesics on a prescription may be more expensive for patients in many countries.
Patient education and follow‐up
Patients should be advised to read the patient information leaflet (PIL), accompanying the medication. The patients should be advised on how to take the medication safely and effectively. Also, precautions, side effects or adverse reactions to the medication and appropriate actions which may be required should be discussed. Patients should be followed up to ensure that the medication is effective and welltolerated and to make any necessary adjustments to the treatment plan.
1.2 NON‐NARCOTIC ANALGESICS
Non‐narcotic analgesics, also known as non‐steroidal anti‐inflammatory drugs (NSAIDs), are the most frequently used analgesics across the board in clinical medicine as well as dentistry. In addition to their analgesic effects, these drugs also have anti‐inflammatory, antipyretic and antiplatelet activity. These drugs are widely used for short‐term management of mild to moderate pain from various causes including dental pain. More severe pain, particularly of visceral origin, may require management with opioid analgesics either alone or in combination with NSAIDs.
1.2.1 MECHANISM OF ACTION
Tissue injury leads to breakdown of membrane phospholipids by the enzyme phospholipase A2 (). This results in the release of arachidonic acid (AA) from the membrane phospholipids. AA is metabolised via the cyclooxygenase (COX) and lipoxygenase (LOX) pathways as depicted in Figure 1.1.
Figure 1.1 Mechanism of action of non‐steroidal anti‐inflammatory drugs.
Source: Image created in BioRender.com
Most NSAIDs are non‐selective inhibitors of COX and target the two main isoforms of COX, i.e., COX‐1 and COX‐2. COX catalyses the formation of prostaglandins and thromboxane from AA. Aspirin inhibits COX irreversibly, while the other NSAIDs (e.g., indomethacin and diclofenac) cause reversible inhibition of COX. Steroids inhibit PLA2 and block both the COX and LOX pathways.
The analgesic effect results from inhibition of prostaglandin synthesis (especially inhibition of PGE2) as well as inhibition of bradykinin release from high‐molecular‐weight (HMW) kininogens in the blood plasma and tissues.
1.2.2 SIDE EFFECTS
The main side effects of NSAIDs are gastric imitation, nephrotoxicity and hypersensitivity (also see individual drugs).
1.2.3 SELECTIVE COX‐2 INHIBITORS
Traditional NSAIDs, such as aspirin, ibuprofen and naproxen, block both isoforms of COX, i.e., COX‐1 and COX‐2, which can lead to unwanted side effects such as stomach ulcers and bleeding.
COX‐2 inhibitors are a class of drugs that selectively block the enzyme cyclooxygenase‐2 (COX‐2). The rationale for using COX‐2 inhibitors is to reduce inflammation and pain without affecting the other functions of COX‐1, another form of the enzyme that is involved in the production of protective prostaglandins that help maintain the health of the stomach lining and regulate blood clotting.
However, COX‐2 inhibitors have been associated with an increased risk of cardiovascular events such as heart attack and stroke, particularly when used at high doses or for long periods of time. This has led to a sharp decline in the use of COX‐2 inhibitors. Although some COX‐2 inhibitors (e.g., celecoxib and meloxicam) may still be used for short‐term pain relief associated with conditions such as osteoarthritis, and rheumatoid arthritis, there is little indication for their use in dentistry. Extreme caution is required when using COX‐2 inhibitors in patients with cardiovascular risk factors and medical advice must be sought.
NSAIDs are used as first‐line therapy for acute dental pain. Paracetamol and ibuprofen alone or in combination are one of the most common NSAIDs used in the management of oral surgical and dental pain1–3. The following section discusses the most common oral and topical NSAIDS which are used in the management of pain and inflammation associated with oral and dental disorders.
1.3 COMMON NON‐STEROIDAL ANTI‐INFLAMMATORY AGENTS USED IN DENTISTRY
1.3.1 ASPIRIN (ACETYL SALICYLIC ACID)
Indications
: Mild to moderate pain, pyrexia, antiplatelet activity (see
Chapter 15
).
Cautions
: Impaired renal or hepatic function; dehydration; elderly; pregnancy; asthma, allergic disease; alcohol (gastric bleeding).
Contra‐indications
: Children under 12 years, breastfeeding, gastrointestinal ulceration, and blood dyscrasias such as haemophilia and thrombocytopenia.
Hypersensitivity
: Contraindicated in patients with hypersensitivity to aspirin or other NSAIDs; asthma; angioedema; rhinitis; urticaria.
Side effects
: GIT irritation; slight asymptomatic blood loss; increased bleeding time; bronchospasm; skin reactions in hypersensitive patients.
Interactions
: Enhances effects or oral anticoagulants (bleeding); oral hypoglycaemics (hypoglycaemia); corticosteroids (peptic ulceration).
COMMERCIAL PREPARATIONS:
Aspirin
Tablets, aspirin 300 mg
ROUTE OF ADMINISTRATION AND DOSE:
By mouth, 300–900 mg every 4–6 hours, maximum 4 g daily. Child not recommended.
1.3.2 PARACETAMOL (ACETAMINOPHEN)
Paracetamol is one of the most widely used analgesic and antipyretic worldwide. It is similar to aspirin in efficacy but has no demonstrable anti‐inflammatory/antiplatelet activity; it is less irritant to the stomach than aspirin, and thus it is generally preferred to aspirin, especially in the elderly.
Indications
: Mild to moderate pain, pyrexia.
Cautions
: Hepatic and renal impairment; alcohol dependence.
Side effects
: Rashes; blood disorders; acute pancreatitis reported after prolonged use; liver damage; renal damage (less frequently).
Overdosage
: Nausea, vomiting, right subcostal pain; hepatocellular necrosis; renal necrosis.
COMMERCIAL PREPARATIONS:
Panadol
®
Soluble tablets, paracetamol 500 mg
Oral suspension, paracetamol 250 mg/5 mL
Oral suspension, paracetamol 120 mg/5 mL
ROUTE OF ADMISSION AND DOSE:
By mouth, 0.5 g every 4–6 hours, maximum 4 g daily. Child 1–5 years 120–250 mg and 6–12 years 250–500 mg.
1.3.3 IBUPROFEN
Indications
: Fever; pain and inflammation; mild to moderate pain; post‐operative analgesia; musculoskeletal disorders including pain related to the temporomandibular joint.
Cautions
: Hypersensitivity to other NSAIDs; asthma, Crohn's disease, ulcerative colitis; over 65 years.
Contra‐indications
: Renal impairment; cardiac impairment; hepatic impairment; peptic ulceration.
Side effects
: GIT discomfort, nausea, diarrhoea, bleeding, ulceration occasionally; hypersensitivity reactions; headache, dizziness; vertigo.
COMMERCIAL PREPARATIONS AND DOSE:
Nurofen
®
Caplets, ibuprofen, 200 mg
Liquid capsules, ibuprofen 400 mg
Caplets, ibuprofen, 684 mg
Dose
: 1.2–1.8 g daily in 3–4 divided doses, maximum 2.4 g daily.
Paediatric
:
Chewable capsules, ibuprofen 100 mg
Oral suspension, ibuprofen 100 mg/5 mL
Dose
: 20 mg/kg daily.
Brufen
®
Coated tablets, ibuprofen 200 mg, 400 mg, 600 mg
Syrup, 100 mg/5 mL
Granules effervescent, 600 mg/sachet
Dose
: 1.2–1.8 g daily in 3–4 divided doses, maximum 2.4 g daily; child 20mg/kg daily not for children under 7 years.
Brufen Retard
®
Tablets, m/r, ibuprofen 800 mg
Dose
: 2 tablets daily as a single dose, preferably in the early evening, increased in severe cases to 3 tablets in 2 divided doses. Child not recommended.
Topical
Ibugel
®
Topical, ibuprofen gel 5%; apply 3 times daily.
1.3.4 NAPROXEN
Indications
: Similar to ibuprofen.
Cautions
:
Contra‐indications
:
Side effects
: Similar to ibuprofen, though slightly more.
COMMERCIAL PREPARATIONS AND DOSE:
Naprosyn
®
Tablets, naproxen 250 mg, 375 mg, 500 mg; available as gastro‐resistant enteric‐coated preparations
Dose
: 500 mg twice daily, preferably after food. Child under 16 years not recommended.
Synflex
®
Tablets, naproxen sodium 550 mg
Dose
: 500 mg twice daily, preferably after food. Child under 16 years not recommended.
1.3.5 FLURBIPROFEN
Indications
: Similar to ibuprofen.
Cautions
:
Contra‐indications
:
Side effects
: Similar to ibuprofen, though slightly more.
COMMERCIAL PREPARATIONS AND DOSE:
Froben
®
Tablets, flurbiprofen 50 mg
Dose
: By mouth, 150–200 mg daily divided doses, increased in acute conditions to 300 mg daily. Child not recommended.
Froben SR
®
Capsules, m/r, flurbiprofen 200 mg
Dose
: 1 capsule daily, preferably in the evening. Child not recommended.
Ansaid
®
Tablets, flurbiprofen 100 mg
Dose
: By mouth, 150–200 mg daily divided doses, increased in acute conditions to 300 mg daily. Child not recommended.
1.3.6 MEFENAMIC ACID
Indications
: Similar to ibuprofen.
Cautions
:
Contra‐indications
: Similar to other NSAIDs; especially contraindicated in inflammatory bowel disease; blood tests required during long‐term treatment; porphyria.
Interactions
: Enhances effects of oral anticoagulants (bleeding); oral hypoglycaemics (hypoglycaemia).
Side effects
: Drowsiness; diarrhoea or rashes (withdraw treatment); thrombocytopenia, haemolyticanaemia and aplastic anaemia; convulsions on overdose.
COMMERCIAL PREPARATIONS:
Ponstan
®
Capsules, mefenamic acid 250 mg
Paediatric oral suspension, mefenamic acid 50 mg/5 mL
Ponstan Forte
®
Tablets, mefenamic acid 500 mg
ROUTE OF ADMINISTRATION AND DOSE:
By mouth, 500 mg 3 times daily preferably after food. Child over 6 months, 25 mg/kg daily in divided doses for not longer than 7 days, except in juvenile arthritis.
1.3.7 DICLOFENAC SODIUM
Indications
: Similar to ibuprofen.
Cautions
:
Contra‐indications
:
Side effects
: Similar to naproxen (see earlier notes); avoid in porphyria.
COMMERCIAL PREPARATIONS AND DOSE:
Voltarol
®
Tablets e/c diclofenac sodium, 25 mg, 50 mg
Dose
: By mouth, 75–150 mg daily in 2–3 divided doses, preferably after food.
Maximum total daily dose by any route 150 mg.
Voltarol 75 mg SR
®
Tablets m/r diclofenac sodium, 75 mg
Dose
: By mouth, 75 mg 1–2 times daily, preferably with food. Child not recommended.
Topical
Emulgel
®
Diclofenac dimethylammonium salt, 1.16% (equivalent to diclofenac sodium 1%). Apply 3–4 times daily.
1.3.8 INDOMETHACIN
Indications
: Mild to moderate pain and inflammation; musculoskeletal disorders including temporomandibular joint.
Cautions
:
Contra‐indications
: Caution in epilepsy, parkinsonism psychiatric disturbances; blood and ophthalmic examination are advised during prolonged therapy; avoid rectal administration in proctitis and haemorrhoids. Dizziness may affect the performance of skilled tasks, e.g., driving.
Side effects
: Similar to naproxen (see earlier notes); frequently GIT disturbances (including diarrhoea) GIT ulceration and bleeding headache, dizziness, light‐headedness; rarely confusion, insomnia, convulsions, depression, syncope; blood disorders (particularly thrombocytopenia), hypertension, hyperglycaemia, blurred vision, and peripheral neuropathy.
COMMERCIAL PREPARATIONS AND DOSE:
Indocid
®
Capsules, indomethacin 25 mg, 50 mg
Suspension, indomethacin 25 mg/5 mL
Dose:
By mouth, 50–200 mg daily in divided doses with food. Child not recommended.
Maximum total daily dose by any route 150–200 mg.
Indocid R
®
Capsules, m/r indomethacin 75 mg
Dose
: By mouth, 75 mg 1–2 times daily preferably with food. Child not recommended.
1.4 NARCOTIC ANALGESICS
Narcotic analgesics, also known as opioids, are a class of strong pain‐relieving medications that are derived from the opium poppy plant or synthesised to mimic the effects of these natural substances. Narcotic analgesics work by binding to opioid receptors in the brain and spinal cord, which can result in pain relief, sedation, and euphoria.
Opioid overdose is a growing public health problem globally and has given rise to an opioid crisis in the United States and Canada with an estimated 600,000 deaths due to opioid overdose in the last two decades4. Opioid prescriptions have also increased in the United Kingdom and have been associated with a remarkable increase in incidences of overdose and hospitalisations5. Like other health professionals, dentists should also limit the use of narcotic analgesics due to risks of addiction and overdose. Narcotic analgesics should be prescribed when absolutely necessary, and the dose should be kept low and the duration must also be limited.
1.4.1 MECHANISM OF ACTION
Opioids combine selectively with many recognition sites throughout the body. Brain loci involved in the transmission of pain and in the alteration of reactivity to nociceptive (painful) stimuli appear to be primary site of opioid action. Specific opioid receptors (Mu, kappa, sigma, and delta receptors) are distributed in the dorsal horn of spinal cord, certain subcortical regions of the brain, and also in several thalamic and hypothalamic areas – the major areas of central nervous system (CNS) concerned with nociception. These nociceptive sites in the brain also contain high concentrations of endogenous peptides (opiopeptins) such as β‐endorphin and enkephalins which have opiate‐like properties. These endogenous peptides are released from the brain as a physiological response to pain. Morphine and other opioid analgesics mimic the action of these endogenous ligands with their receptors; this interaction gives rise to their pharmacological effects.
Neurotransmitters showing depressed release after opioid administration include acetylcholine, norepinephrine, dopamine, 5‐hydroxytryptamine and substance P. This depressed release of neurotransmitters is related to decreased calcium entry or enhanced potassium entry across specific ion channels. However, chronic exposure to opioids leads to an elevation of intracellular calcium; this mechanism is responsible for tolerance and physical dependence.
1.4.2 SIDE EFFECTS
Opioid analgesics share many side effects, though qualitative and quantitative differences exist. The most common include nausea, vomiting, constipation and drowsiness. Larger doses produce respiratory depression and hypotension. Drowsiness may affect the performance of skilled tasks (e.g., driving); effects of alcohol are enhanced. Drug tolerance and dependence is a recognised risk with all narcotic drugs.
1.4.3 OVERDOSE
Varying degrees of coma, respiratory depression, pinpoint pupils (miosis).
Acute opioid overdose may be managed with appropriate antidotes such as naloxone (Narcan®) and Levallorphan (Larfan®).
1.4.4 COMMON NARCOTIC ANALGESICS
A variety of narcotic analgesics are available for medical use including the following:
Morphine (Oramorph
®
)
Diamorphine hydrochloride (Heroin)
Pethidine (CD Pethidine
®
)
Codeine (Codeine phosphate
®
)
Fentanyl (Actiq
®
, Abstral
®
)
Oxycodone (Oxaydo
®
)
Hydrocodone (Hysingla
®
)
Tramadol (Ultram
®
)
Buprenorphine (Temgesic
®
)
Majority of the aforementioned narcotic analgesics are unsuitable in dental settings due to serious side effects and risks associated with their use and are best prescribed under medical care. However, narcotic analgesics mentioned in the following text may be used for the management of pain by dentists.
Codeine Phosphate
Indications
: Mild to moderate pain.
Cautions
: Hypotension, hypothyroidism, asthma, decreased respiratory reserve, prostatic hypertrophy, pregnancy, breastfeeding; precipitate coma in hepatic impairment, renal impairment; elderly and debilitated; should be avoided altogether in Children less than 1 year.
Contra‐indications
: Acute respiratory depression; acute alcoholism; paralytic ileus, acute abdomen, raised intracranial pressure, head injury; pheochromocytoma (risk of presser response to histamine release).
Side effects
: Nausea, vomiting (initial stages), constipation; drowsiness; larger doses produce respiratory depression, and hypotension, also ureteric or biliary spasm, dry mouth, sweating, headache, flushing, vertigo, bradycardia, tachycardia, palpitations, hypothermia, hallucinations, dysphoria, mood changes, dependence, miosis, decreased libido, rashes, urticaria and pruritus.
Overdosage
: Coma, respiratory depression, pinpoint pupils (miosis).
COMMERCIAL PREPARATIONS:
Codeine phosphate
®
Tablets, codeine sulphate 15 mg, 30 mg, 60 mg
Syrup, codeine sulphate 25 mg/mL
ROUTE OF ADMINISTRATION AND DOSE:
By mouth, 30–60 mg every 4 hours, maximum 240 mg daily. Child 1–12 years, 3 mg/kg daily in divided doses.
COMPOUND PREPARATIONS:
Compound preparations contain a combination of NSAIDs and narcotic analgesics and may be used for management of pain in dental settings.
Co‐Codamol (Codeine phosphate and paracetamol)
Panadeine
®
Tablets, co‐codamol 8/500 (codeine phosphate 8 mg, paracetamol 500 mg).
Dose
