INTERACTION BETWEEN SPECIFIC DISEASES AND DENTAL PHARMACOLOGY
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
Narcotics and cold air.
Clarithromycin) or Ciprofloxacin, may cause theophylline toxicity.
may cause asthma attack.
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.
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.
oxide accumulates in enlarged air spaces in lung with emphysema. If must use
so don’t use. Narcotics and barbiturates can cause respiratory depression.
follow Adrenal Supplementation Regimen. No office GA or IV sedation.
acting oral agents must be stopped sooner. Glyburide (Diabeta, Micronase) stop 24
hours pre-op, Chlorpropamide (Diabinese) 36 hours and Metformin (Glucophage)
procedures 4-30 hours after dialysis and 24-48 hours prior to next dialysis.
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.
clindamycin and metronidazole (Flagyl).
(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.
Dysfunction can use drugs in limited quantity (Three cartridges 2% lidocaine is
108 mg, ok).
AIDS: Antibiotic prophylaxis.
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
Tarcolimus, a potent macrolide immunosuppressant, is nephrotoxic, neurotoxic
and diabetogenic. Macrolide antibiotics, azole antifungals and corticosteroids
Increase tarcolimus concentration.
arrhythmias when used with tacrolimus and cyclosporine.
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.
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.
Penicillins, cephalosporins, erythromycin and clindamyacin not teratogenic.
Don’t use aminoglycosides, tetracycline, metronidazole and sulfonamides.
Increases risk of maternal infection and neonatal sepsis, don’t use.
Don’t use Pro-Banthine.
Cyclobenzaprine (Flexeril) one of only possible drugs to use.
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.
Well controlled, no treatment problems.
Regimen. Steroids also delay healing, cause hypertension, more susceptible
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.
Codeine drug of choice for pain control.
and chloramphenicol. Also penicillin, streptomycin and isoniazid.
CNS depressant, increases effects of narcotics, benzodiazepines and
Chronic users may require greater anesthetic dosages.
Medical problems include liver disease and infectious diseases (HIV,
infectious hepatitis and endocarditis). Intravenous drug use history, consider
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
thrombocytopenia. Don’t use NSAIDs with these medications. No
propoxyphene or erythromycin with carbemazepine.
minutes, slightly increased bleeding risk, >20 minutes, significant bleeding risk.
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.
alcohol. Increased anticholinergic effects with anticholinergics and other
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).
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.
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.
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
If patient taking Digoxin (Lanoxin) check with physician prior to using
vasoconstrictor in local anesthetic.
with neuroleptic and heterocyclic medications.
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
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.
Tranylcypromine (Parnate). Use local anesthesia without vasoconstrictor
whenever possible. If must use limit to two carpules 1:100,000 epinephrine
within 15 minutes, aspirate.
Local anesthesia with vasoconstrictor can cause life threatening arrhythmias and
hypertensive crisis. General anesthetics can be dangerous as are mixing with
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
effectiveness. Acts synergistically with aminoglycosides. Probenecid will increase
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, Clarithromycin (Biaxin) and Azithromycin (Zithromax)
nondepolarizing muscle relaxants and hydrocarbon inhalation anesthetics.
May reduce effectiveness of oral contraceptives. Probenecid decreases elimination.
Cephalexin (Keflex, Keftab) 1st generation
Cefadroxil (Duricef) 1st generation
Cefprozil (Cefzil) 2nd generation
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
Tetracycline (Achromycin, Sumycin, Tetracyn)
Tetracycline Periodontal Fibers (Actisite)
Increases coumadin and benzodiazepine activity. Rifampin decreases fluconazole
activity. Arrhythmias possible with antihistamines.
None with Disulfiram (Antabuse), causes psychosis.
Clotrimazole (Mycelex Troche)
Increases activity of cyclosporines and sulfonylureas.
Increased CNS side effects with zidovudine (AIDS drug) and probenecid.
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.
Propionic Acid Derivative NSAIDs
Same as salicylates. Nephrotoxic with acetaminophen. Increased photosensitivity
with tetracycline. Increased toxicity diuretics. Not with methotrexate.
Ketoprofen (Orudis, Oruvail)
Naproxen (Aleve, Anaprox, Naprosyn)
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.
Acetic Acid Derivative NSAIDs (continued)
Diclofenac (Cataflam, Voltaren)
Decreased effect with antacids. Increased toxicity with digoxin, methotrexate,
anticoagulants, phenytoin and sulfonylureas. Increased toxicity with sulfonamides,
indomethacin, hydrochlorothiazide, lithium and acetaminophen.
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.
Increases effects of oral anticoagulants. Decreased effect with aspirin. None with
Don’t use with aspirin, increased activity of oral anticoagulants. Other reactions
Same as other NSAIDs.
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.