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Appendix I: Alphabetical Monograph Listing
The monographs that follow represent either prototypes for their respective drug classes or drugs that have significant use or clinical considerations in dentistry. The chapters containingthe primary discussion of these monographs are listed. The drugs are arranged alphabetically, bytheir generic name.
Information in these monographs includes– Generic NameBrand Name(s)Use(s)Mechanism of actionUsual DoseSide EffectsDental Considerations Generic Name: Acetaminophen (see Chapter Eight, Analgesics)
Brand Names: Tylenol, Panadol, Datril
Uses: mild non-prescription analgesic
Mechanism of action: a mild, reversible COX enzyme inhibitor without uricosuric (does not cause
changes in uric acid levels, therefore not useful for gout) or anti-inflammatory activity; also, no
anticoagulant activity as seen with salicylates
Usual Dose: 5 grains (325mg) every 4 to 6 hours as needed
Side Effects: excessive use can lead to liver damage, with suicide attempts being treated with
acetylcysteine (Mucomyst)
Dental Considerations: does not possess anti-inflammatory properties, may therefore be less effective
with pain associated with inflammation before or following dental procedures
Generic Name: Acetaminophen with codeine (see Chapter Eight, Analgesics)
Brand Name(s): Tylenol #2 (15mg codeine), #3 (30mg codeine), or #4 (60mg codeine)
Use(s): moderate prescription analgesic – controlled substance
Mechanism of action:
Usual Dose:
one tablet every four to six hours as needed for pain
Side Effects: fatigue, CNS depression, respiratory depression, enhanced sedation with other CNS
depressants, constipation
Dental Considerations: codeine may cause some xerostomia
Acetaminophen with hydrocodone (see hydrocodone with acetaminophen/Vicodin)
Generic Name: Acetylcholine ophthalmic solution
Brand Name: Miochol
Use(s): Miochol is used to constrict the pupil of the eye quickly and completely during cataract surgery
and other types of eye surgery
Mechanism of action: Cholinergic action in the eye
Usual dose: 1-4 drops of solution to the eye.
Side effects: rarely shows symptoms of systemic effects; however, it may slow heart rate, cause dizziness
or lightheadedness due to low blood pressure, flushing, sweating or abnormal vision.
Dental considerations: While rare, it may increase salivation and SLUD-like cholinergic activity
Generic Name: Albuterol Inhalation (Proventil)
Brand Names: ProAir HFA, Proventil (HFA), Ventolin HFA
Uses: treat or prevent bronchospasm
Mechanism of action: A sympathomimetic (adrenergic) agent that stimulates beta-2 adrenergic receptors
in the lungs, resulting in bronchodilation.
Usual Dose: 2-4 mg (1-2 inhalations) 3-4 times a day
Side Effects: Headache, nausea, restlessness, nervousness and tremors, throat dryness and irritation,
pharyngitis, blood pressure changes, heartburn and transient wheezing.
Dental Considerations: Monitor vital signs at every appointment because of the cardiovascular and
respiratory side effects. Assess salivary flow as a factor in caries, periodontal disease, and candidiasis.
Adrenergic agents may cause xerostomia and alterations of taste perception.
Generic Name: Aspirin (ASA, acetylsalicylic acid) (see Chapter Eight , Analgesics)
Brand Name(s): Bayer’s Aspirin
Use(s): mild analgesic and anti-inflammatory agent; also used as a means of preventing platelet
coagulation
Mechanism of action: prostaglandin inhibition
Usual Dose: for analgesia, one 5 grain (325mg) tablet every four to six hours as needed for mild pain; for
anticoagulant effect, anywhere from 81mg to 325mg, taken once daily
Side Effects: GI irritation, nausea; allergies occur in about 5% of the population, more frequently among
those patients with asthma
Dental Considerations: anticoagulant effect may result in increased gingival bleeding during procedures
Generic Name: Atropine
Brand Names: Sal-Tropine, Isopto Atropine (ophthalmic drops)
Mechanism of Action: Prototype drug for anticholinergic activity. Atropine inhibits action of
acetylcholine or other cholinergic stimuli at postganglionic cholinergic receptors, including smooth
muscles, secretory glands, and CNS sites. It also reduces secretion of many organs thereby providing a
clear operating field pre-op.
Usual Dose: Adults: 0.4 to 0.6 mg every 4-6 hours, children: use lowest effective dose (see chart in text).
Side Effects: Atropine creates the classic anti-SLUD (anticholinergic) environment, with effects that
vary with the dose. These include irregular or rapid heart rate, flushing, eye pain, headache, sleepiness,
dizziness, increased intracranial pressure, blurred vision, sensitivity to light, changes in taste,
xerostomia, decreased sweating, constipation, urinary retention, along with possible hallucinations,
muscle twitching, seizures, dermatitis, dry mucous membranes, and tongue chewing.
Dental Considerations: Increase in caries due to xerostomia and oral trauma due to tongue chewing.
Generic Name: Atropine with diphenoxylate - combination product
Brand Name(s): Lomotil
Use(s): oral anti-diarrheal
Mechanism of action: takes advantage of (1) the opiate receptor response associated with constipation
and (2) the anticholinergic (anti-SLUDP) activity of atropine
Usual Dose: 1 tablet after each bout of diarrhea, with a maximum of 8 tablets in a 24 hour period
Side Effects: sedation; prolonged use can result in dependence
Dental Considerations: the opiate effect and the anticholinergic effect will combine to cause profound
xerostomia; patients using this drug routinely will experience an increase in plaque and caries
Generic Name: Bethanechol
Brand Names: Urecholine, Duvoid
Uses: Treat urinary retention
Mechanism of Action: Cholinergic drug, stimulates parasympathetic nervous system, increasing tone to
muscles of urinary bladder
Usual Dose: 25-50mg three or four times a day
Side Effects: wheezing or tightness in chest, vomiting, blurred vision, frequent urge to urinate, stomach
discomfort or pain, fall in blood pressure
Dental Considerations: Monitor vital signs at every appointment due to cardiovascular and respiratory
side effects. After supine positioning, have patient sit upright for at least 2 minutes to avoid orthostatic
hypertension. Cholinergic effects may result in increased salivation.
Generic Name: Capscacin (topical)
Brand Names:
Capsin, Capzasin, Zostrix, Zostrix HP.
Use: to help alleviate the pain associated with herpes zoster (“shingles”)
Mechanism of Action: May deplete and prevent reaccumulation of substance P, principal transmitter of
pain impulses, from periphery to CNS. Usual Dose: Apply to affected area 3 times/day.
Side Effects: Burning, stinging, reddened skin. Will cause intense burning if introduced into t he eyes or
other mucosal tissues.
Dental Considerations: may cause irritation if inadvertently applied to the gums.
Generic Name: Carbachol (Isopto-Carbachol)
Brand Names: Carboptic, Isopto carbachol, Carbostat, Miostat
Uses: treating glaucoma
Mechanism of Action: A direct-acting parasympathomimetic agent that stimulates cholinergic receptors,
contracting the iris and other parts of the eye, resulting in reduction of eye pressure
Usual Dose: 1-2 drops of 0.75-3% solution in affected eye(s) up to 3 times daily
Side Effects: blurred vision, eye pain, headache, irritation of eyes, twitching of eye lid
Dental Considerations: avoid dental light in patient's eyes; offer dark glasses for patient comfort.
Generic Name: Carbamazepine (Tegretol)
Brand Name: Tegretol.
Use: antiseizure, for pain associated with trigeminal neuralgia (“tic doloreaux”), and as adjunct therapy
in bipolar disorder
Mechanism of Action: CNS depressant activity diminishes frequency of nerve transmission, raising the
seizure threshold
Usual Dose: 200mg three times daily
Side Effects: Dizziness, drowsiness, nausea, unsteadiness and vomiting. Rarely may cause severe blood
disorders (aplastic anemia and agranulocytosis).
Dental Considerations: May cause xerostomia, leading to ulcers or sores in the mouth
Generic Name: Celecoxib
Brand Name: Celebrex
Use(s): Anti-inflammatory drug for arthritis
Mechanism of action: COX-2 inhibitor (see Chapter Eight, Analgesics, for full discussion)
Usual Dose: 100-200mg once or twice a day
Side Effects: Despite the focus on COX-2 inhibition, with the presumed protective effects on the GI
lining, patients still experience stomach upset; it should be taken with food. Recent studies (2005)
indicate a correlation to heart failure while using COX-2 inhibitors; whether this results in the removal of
COX-2 inhibitors from the market is yet to be seen
Dental Considerations: None of clinical significance
Generic Name: Cephalexin
Brand Names: Keflex, Keftab.
Use: First-generation cephalosporin antibiotic
Mechanism of Action: bactericidal binding to bacterial cell membranes, inhibiting cell wall synthesis.
Usual Dose: (adult) 250mg-500mg four times daily, (children) 25 to 100 mg/day in divided doses.
Side Effects: Vomiting, diarrhea, pseudomembranous colitis (from overgrowth of Clostridium difficile),
renal impairment, candidal superinfection (oral and vaginal), skin rashes.
Dental Considerations: Candidal overgrowth, erythema multiforme, hemorrhaging (increased bleeding of
gingival tissue).
Generic Name: Cevimeline
Brand Name: Evoxac
Use: treatment of xerostomia due to Sjogren disease
Mechanism of Action: cholinergic activity increases the production of saliva.
Usual Dose: 30 mg, three times daily
Side Effects: excessive sweating, nausea, runny or stuffy nose, abdominal pain, loss of appetite, shortness
of breath, blurred vision, diarrhea, increased or painful urination
Dental Considerations: Assess salivary flow as a factor in caries, periodontal disease, and candidiasis.
Place on frequent recall to assess effectiveness. Monitor vital signs at every appointment due to
cardiovascular and respiratory side effects.
Generic Name: Chlorpheniramine
Brand Name: Chlor-Trimeton
Use: Antihistamine
Mechanism of action: Blocks the effect of histamine at histamine receptors. Histamine can produce
symptoms of sneezing, itching, watery eyes, and runny nose.
Usual Dose: 4 mg every 6-8 hours, up to 24 mg per day
Side Effects: Drowsiness, dizziness, muscular weakness, hypotension, dry mouth, nose, throat, and lips,
urinary retention, thickening of bronchial secretions. Additive effects seen with alcohol.
Dental Considerations: Assess salivary flow as a factor in caries, periodontal disease, and candidiasis.
Consider semisupine chair position for patients with respiratory disease.
Generic Name: Ciprofloxacin
Brand Names: Cipro, Cipro XR, Cipro HC (ophthalmic)
Uses: A fluoroquinolone antibiotic to treat bacterial infections.
Mechanism of Action: Inhibits microbial protein DNA replication and transcription
Usual Dose: 250-500mg every 12 hours
Side Effects: Abdominal pain/discomfort, diarrhea, headache, nausea, rash, restlessness, vomiting,
potential for candidial overgrowth. Slows the metabolism of many other drugs, including caffeine.
Dental Considerations: Minimize exposure to sunlight. Avoid dental light in patient's eyes; offer dark
glasses for patient comfort
Generic Name: Clonidine
Brand Names: Catapres (oral) or Catapres TTS (7-day topical patch)
Uses: Management of hypertension
Mechanism of Action: Works on central alpha-adrenergic receptors to inhibit sympathetic action in the
cardiovascular system. Vasodilation results
Usual Dose: 0.1-0.3mg once to twice daily for oral treatment, the patch delivers 0.1-0.3mg daily over a 7
day duration
Side Effects: Constipation, dizziness, drowsiness, dry mouth, nausea and vomiting. Clonidine should not
be discontinued abruptly, since this may result in rapid and severe rebound hypertension.
Dental Considerations: Orthostatic hypotension is a possibility with any drug to treat hypertension.
Xerostomia is a possible a factor in dental caries, periodontal disease, and candidiasis. Monitor vital
signs every appointment due to cardiovascular side effects.
Generic Name: Diazepam
Brand Names: Valium, Diastat
Use: anti-anxiety drug, also used as muscle relaxant or for severe seizures
Mechanism of Action: Prototype for the benzodiazepine group of antianxiety drugs. Potentiates action of
GABA, the inhibitory neurotransmitter, resulting in increased neural inhibition and CNS depression.
Used to treat anxiety disorders, alcohol withdrawal symptoms, or muscle spasms.
Usual Dose: IM/IV 2 to 20 mg every 3 to 4 hrs, oral 2-10mg once to three times daily
Side Effects: Sedation, dizziness and headache, blurred vision, depressed hearing, xerostomia
Dental Considerations: xerostomia. If used before an appointment to treat dental-office anxiety, the
patient should have someone available for the drive home.
Generic Name: digoxin
Brand Names: Lanoxin, Lanoxicaps, Digitek
Uses: antiarrhythmic, for treating (congestive) heart failure and reducing frequency of chronic atrial
fibrillation
Mechanism of Action: Digitalis glycoside increasing the force of contraction of the heart and slowing
heart rate
Usual Dose: 0.125-0.25mg once a day
Side Effects: Diarrhea, irregular heart beat, loss of appetite, vomiting, weakness, nausea; disruption of
color vision (especially blue/green) and appearance of “halos” around bright lights
Dental Considerations: Monitor vital signs every appointment due to cardiovascular side effects. Avoid
dental light in patient's eyes; offer dark glasses for patient comfort. Use vasoconstrictors with caution, in
low doses, and with careful aspiration. Avoid use of gingival retraction cord with epinephrine.
Generic Name: diphenydramine
Brand Name(s): Benadryl
Use(s): antihistamine, occasionally used as a sleep aid - considered the most sedative of all
antihistamines
Mechanism of action:
blocks the effect of histamine at receptor sites; has no effect on histamine already
released during an allergic reaction
Usual Dose: 25 to 50mg every four to six hours
Side Effects: most sedative of all antihistamines; xerostomia
Dental Considerations: patients using diphenhydramine on a continuous basis will have pronounced
xerostomia
Generic Name: donepizil
Brand Name(s): Aricept
Use(s): treatment of Alzheimer’s Disease
Mechanism of action: cholinergic activity in the central nervous system
Usual Dose:
Side Effects:
primarily gastrointestinal, due to the cholinergic nature of the drug. Expect a SLUD
response
Dental Considerations: patients may present with excessive salivation during treatment with donepizil
Generic Name: Epinephrine
Brand Names: Susphrine, Asthmanefrin
Mechanism of Action: prototype agent for adrenergic response; bronchodilation from beta-agonist effect,
increase in heart rate during cardiac emergencies
Usual Dose: 0.3mg-1mg SQ or IV
Side Effects: Tachycardia, headache, loss of appetite, nausea, nervousness and tremors.
Dental Considerations: xerostomia, increase in heart rate. If the patient has been sensitized to
catecholamines during general anesthesia, the use of a lidocaine-epinephrine combination in local
anesthesia may induce tachycardia
Generic Name: Erythromycin
Brand Names: E-Mycin, EES, Ilosone
Uses: a macrolide, bacteriostatic antibiotic for treating infections with susceptible bacteria
Mechanism of action: binds to bacterial ribosomes, inhibiting bacterial protein synthesis.
Usual Dose: 250-500mg every 6 hours
Side Effects: Abdominal cramping or discomfort, thrombophlebitis, nausea, vomiting, diarrhea, rash and
urticaria.
Dental Considerations: Avoid dental light is patient's eyes: offer dark glasses for patient comfort and
protect patient's eyes from accidental spatter during treatment.
Generic Name: Estrogen
Brand Names: Menest or Ogen (Esterified Estrogen, derived from plant sources) , Premarin (Conjugated
Estrogens from urine of pregnant mares)
Use: hormonal replacement therapy to relieve symptoms of menopause
Mechanism of Action: necessary for growth and development of female reproductive system and
secondary sex characteristics; conserves calcium and phosphorus and encourages bone formation;
overrides stimulatory effects of testosterone.
Usual Dose: 0.3mg to 2.5mg (esterified tablets), 0.3mg-1.25mg (conjugated tablets)
Side Effects: Conjugated estrogens associated with increased breast cancer rates. Thrombophlebitis and
pulmonary embolism, heart attacks and hypertension. Headaches leading to migraine, with depression;
anxiety and emotional lability, scalp hair loss and urticaria possible. Other risks include endometrial
carcinoma and breakthrough bleeding; dysmenorrhea or amenorrhea; vaginal candidiasis and
premenstrual-like syndromes.
Dental Considerations: Possible increased sensitivity to pain
Generic Name: Fentanyl
Brand Name(s): Duragesic (patches), Actiq (lozenges), Sublimaze (injection)
Use(s): Powerful narcotic analgesic (Schedule II)
Mechanism of action:
Usual Dose:
for the patches, one patch is applied and replaced every 72 hours, in a dosage and delivery
range of 25-100mcg per hour. For the lozenges, the range is one lozenge, allowed to dissolve orally, with
a per dose range of 200-800mcg. The injection form of fentanyl is used as a surgical analgesic. Very
small amounts of fentanyl provide dramatic pain relief. Fentanyl is used for pain relief in cases of
terminal cancer or severe bone pain.
Side Effects: NOT FOR CASUAL ANALGESIA. In fact, a patient known as “opioid naive” (a first time
user), is specifically contraindicated for the use of fentanyl. Severe respiratory depression may result.
Fentanyl has caused death from inappropriate use. An obvious side effect would be sedation.
Dental Considerations: Like other narcotic analgesics, fentanyl can cause xerostomia. A patient using
fentanyl while seeking dental care will be prone to additive CNS depression if other narcotic analgesics
are provided.
Generic Name: Fluoxetine
Brand Names: Prozac, Prozac Weekly, Sarafem
Use: antidepressant; note: the product Sarafem is the same drug as Prozac, with the supposedly unique
indication of “premenstrual dysphoric syndrome,” a condition that did not exist before the drug Sarafem
appeared on the market
Mechanism of Action: a selective serotonin reuptake inhibitor (SSRI), presumed to be linked to inhibition
of CNS neuronal reuptake of serotonin. For depression, obsessive compulsive disorder, nervous
disorder, and bulimia nervosa
Usual Dose: 10-40mg daily
Side Effects: Headache, insomnia, hypertension, xerostomia, constipation, suicidal ideations
Dental Considerations: xerostomia, taste disruption. Assess salivary flow as a factor in dental caries,
periodontal disease, and candidiasis.
Generic Name: Furosemide
Brand Name: Lasix
Use: loop diuretic
Mechanism of Action: enhances excretion of sodium, chloride and potassium by direct action at the
ascending limb of the loop of Henle. Treats fluid build-up and swelling caused by congestive heart
failure, liver cirrhosis, or kidney disease.
Usual Dose: orally, 20-80mg daily. IV doses, generally given in a hospital setting, have a wide range,
limited by side effects
Side Effects: photosensitivity, tinnitus, dizziness, xerostomia possible. Patient should be monitored for
hypokalemia (low potassium) with chronic use.
Dental Considerations: orthostatic hypotension, xerostomia. After supine positioning, have patient sit
upright for at least 2 minutes before standing to prevent orthostatic hypotension.
Generic Name: Galantamine
Brand Names: Razadyne, Razadyne ER
Use: treatment of Alzheimer’s disease
Mechanism of action: a cholinesterase inhibitor
Usual Dose: initially, 4 mg twice daily, increasing to 8 mg twice daily after four weeks.
Side Effects: cholinergic in nature: nausea, vomiting, diarrhea, anorexia and weight loss, abdominal pain
and insomnia.
Dental Considerations: may have increased salivation
Generic Name: Guiafenesin with Codeine
Brand Name(s): Robitussin AC
Use(s): antitussive cough syrup
Mechanism of action: codeine is an opiate, and all such drugs have the potential for antitussive activity;
see Chapter Eight, Analgesics
Usual Dose:
1 teaspoonful every four to six hours, as needed, for cough
Side Effects: sedation, constipation
Dental Considerations: patients with routine use of products containing codeine may present themselves
with xerostomia, due to the anticholinergic actions seen with the opiates
Generic Name: Heparin
Uses: Anticoagulant
Mechanism of Action: Disruption in the coagulation process
Usual Dose: Subcutaneous, 5000 units every 12 hours. IV doses are usually administered continually at
rates of 1000 units/hour.
Side Effects: Irritation or pain at injection site, black stools (indication of internal bleeding), excessive
bleeding during oral hygiene care, chills, headaches, stomach pain
Dental Considerations: Increased bleeding from gums when brushing or flossing teeth, swelling of the
mouth, face, lips, or tongue. A medical consult is generally considered necessary if oral or maxillofacial
surgery or trauma treatment is required while a patient is being treated with heparin. May need to defer
treatment.
Generic Name: Hydrocodone with acetaminophen (see Chapter Eight, Analgesics)
Brand Name(s): Vicodin, Vicodin ES, Vicodin HP, Lortab, Lorcet, Norco, and many more, all with
minute variations of either the hydrocodone or acetaminophen content, or both)
Use(s): narcotic analgesic, combination product – controlled substance
Mechanism of action: powerful opiate receptor agonist (hydrocodone) coupled with mild analgesia from
acetaminophen (a postulated COX-3 enzyme inhibitor)
Usual Dose: one to two tablets (of those combinations containing 5mg hydrocodone) or just one tablet
(of those combinations with 7.5mg or more of hydrocodone) every four to six hours as needed for pain
Side Effects: CNS depression, respiratory depression, GI upset and nausea (especially with the first
dose), constipation – note: all drugs containing hydrocodone are considered highly addictive
Dental Considerations: hydrocodone may cause some xerostomia; these are also very popular drugs of
abuse and those patients with “drug seeking behavior” will show considerable creativity in trying to
obtain them from whatever source possible, making dental offices a primary target for getting
prescriptions
Generic Name: Ibuprofen
Brand Name(s): Motrin, Advil
Use(s): NSAID for pain and inflammation, see Chapter Eight, Analgesics
Mechanism of action: COX-1 and COX-2 inhibition resulting in a decrease in prostaglandin synthesis
Usual Dose: 200-800mg three to four times daily, as needed for pain; maximum daily dose is 3200mg
(3.2 grams)
Side Effects: stomach upset, nausea; should be taken with food; may interfere with daily aspirin doses
used for prevention of heart attack and stroke
Dental Considerations: may increase bleeding during dental procedures
Generic name: Ipratropium bromide (Atrovent)
Brand Name: Atrovent
Use: Bronchodilating agent
Mechanism of action: Anticholinergic drug derived from the stramonium plant, causing a decrease in
bronchial secretions
Usual Dose: two inhalations up to four times a day. Patients may take additional inhalations as required;
however, the total number of inhalations should not exceed 12 in 24 hours.
Side Effects: nervousness, dizziness, drowsiness, headache, upset stomach, constipation, cough, dry
mouth or throat irritation, skin rash, blurred vision, increased difficulty breathing and heart palpitations
Dental Considerations: xerostomia (dry mouth), edema of the tongue, lips and face.
Generic Name: Isotretinoin
Brand Name: Accutane
Uses: For severe cases of acne
Mechanism of action: A vitamin A derivative (a “retinoid”), isotretinoin uses its high lipid solubility to
decrease sebum production with antikeratinizing and anti-inflammatory effects.
Usual Dose: 0.5-2 mg daily for 15-20 weeks.
Side Effects: Abnormal hair growth, bleeding or swelling of gingiva, changes in menstrual flow, chapped
lips, dry eyes and mouth, peeling skin, voice changes. Photosensitivity and elevation in triglycerides,
nausea, vomiting, and abdominal pain. Very teratogenic; women of child bearing age must be also using
adequate birth control. Has been associated with contributing to or causing depression even years after
use has been discontinued.
Dental Considerations: Patients may rarely develop blood dyscrasias, which can result in infection,
bleeding and poor healing. Xerostomia likely. Apply lubricant to dry lips for patient comfort before
dental procedures.
Generic Name: Lidocaine
Most Common Brand Names: Xylocaine (topical and injection), Lidoderm (topical patch)
Other Brand Names possible: Anestocaine, Anestacon, Corta-Cap Needle Ease, ELA-max, Lida Mantle,
LMX 4, Premjact and Stud 100 (not a dental application), Topicaine, Zilactin-L.
Mechanism of Action: Decreases automaticity in neural cell pathway, decreases action potential duration,
and raises ventricular fibrillation threshold; inhibits conduction of sodium in nerve impulses from
sensory nerves.
Use: local anesthesia or ventricular antiarrhythmic during cardiac emergencies
Usual Dose:
Side Effects:
Few during local anesthesia. However, if injected into a blood vessel, there is the potential
for hypotension, bradycardia, drowsiness, nausea, vomiting, respiratory depresssion, and mental
confusion.
Dental Considerations: Bruising and pain at IM site (may cause hematoma). Be sure to aspirate any
injection before completely administering lidocaine in dental applications.
Generic Name: Lithium
Brand Names: Eskalith, Lithobid, Lithotabs
Uses: Antidepressant, treatment for bipolar disorder
Mechanism of action: May affect the storage, release, and reuptake of neurotransmitters, especially an
increased norepinephrine reuptake or serotonin receptor sensitivity.
Usual Dose: 300 mg 3-4 times daily, adjusted to specific individual patient response
Side Effects: fine hand tremor, polydipsia, polyuria, nausea, and xerostomia. Should never be given with
diuretics, as electrolyte depletion increases toxicity. Vomiting, diarrhea, slurred speech, extreme
drowsiness, or weakness may be early signs of lithium toxicity.
Dental Considerations: Xerostomia (dry mouth), angioedema of the tongue, lips and face.
Generic Name: Meperidine
Brand Name(s): Demerol
Use(s): synthetic opioid analgesic, Schedule II (see Chapter Eight, Analgesics)
Mechanism of action: opiate receptor agonist
Usual Dose: 50mg every four to six hours as needed for pain
Side Effects: sedation, dependence
Dental Considerations: less xerostomia than seen with opiates such as morphine
Generic Name: Methylphenidate (Ritalin, Concerta)
Brand Names: Ritalin, Methylin, Concerta, Daytrana (topical patch), Metadate
Uses: Treat Attention Deficit Disorder, uncontrollable periods of daytime sleep (narcolepsy)
Mechanism of Action: Stimulates central nervous system
Usual Dose: 10 to 60 mg per day in 2 to 3 doses
Side Effects: Dizziness, drowsiness, headache, loss of appetite, nausea, nervousness, stomach pain,
trouble sleeping
Dental Considerations: Monitor vital signs every appointment due to cardiovascular side effects. Assess
salivary flow as a factor in dental caries, periodontal disease, and candidiasis. Use vasoconstrictors with
caution, in low doses, and with careful aspiration.
Generic Name: Methylprednisolone
Brand Names: Medrol (oral), Solu-Medrol (injection), Depo-Medrol (long-acting injection)
Use: Antiinflammatory
Mechanism of Action: Glucocorticoid antiinflammatory agent (a steroidal antiinflammatory)
that modifies body's immune response.
Usual Dose: Adults: 4 to 48 mg/day, based on disease state.
Side Effects: Nausea and vomiting (especially with oral forms). Hypertension, vertigo, impaired wound
healing, ulcerative esophagitis, increased appetite and weight gain (from both increased appetite and
sodium retention)
Dental Considerations: Oral lesions due to immune suppression, with a slower healing response to oral
surgeries
Generic Name: Morphine
Brand Name(s): MS-contin (sustained release form, otherwise “morphine sulfate”), see Chapter Eight,
Analgesics
Use(s): opiate agonist analgesic, Schedule II
Mechanism of action: opiate receptor agoinist
Usual Dose: varies with condition and tolerance of patient; usually 15-30mg every 4 to 6 hours;
sustained release versions can be as high as 200mg once or twice a day
Side Effects: sedation, constipation, dependence
Dental Considerations: may produce xerostomia
Generic Name: naloxone
Brand Name(s): Narcan
Use(s): pure opiate receptor antagonist (see Chapter Eight, Analgesics)
Mechanism of action: opiate antagonist with no intrinsic activity
Usual Dose: 0.4mg, administered by injection, for symptoms of overdose or post-surgical respiratory
depression; usual total maximum dose is 2mg
Side Effects: may cause liver damage with prolonged use; sedation
Dental Considerations: none
Generic Name: Nicotine
Brand Names: Commit, Habitrol, Nicoderm C-Q, Nicorette, Nicotrol,
Use: Aid in smoking cessation
Mechanism of Action: Nicotine is the primary ingredient in tobacco products. Cholinergic nicotinic
receptors accept nicotine from any source, with these controlled quantities being used to reduce cravings
Usual Dose: Transdermal system 8.3 mg-114mg daily, Spray pump 0.5 mg nicotine/actuation, Inhaler
4mg delivered (10mg/cartridge) with each dose. Gum, 2mg if smoking < 25 cigarettes per day, 4mg if
smoking >25 cigarettes per day. (Maximum of 24 pieces per day)
Side Effects: Difficulty breathing; swelling of your face, lips, tongue, or throat, seizures, or chest pain or
uneven heartbeats
Dental Considerations: Aching jaw from the gum, which is tougher than traditional gum pieces. The
adhesive effect of the lozenges has displaced crowns and fillings. Taste sensations are often disrupted,
both as a result and because of this treatment. White patches or sores inside the mouth are more likely
with the inhalers.
Generic Name: Nitroglycerin
Brand Names: Nitro-Dur, Nitrobid, Nitrostat, Minitran, Nitrek
Uses: Preventing angina (chest pain) caused by ischemia (low oxygen) caused by coronary artery disease
Mechanism of Action: A nitrate, causing relaxation of all vascular smooth muscle and dilation of
peripheral arteries and veins. In the heart, the coronary dilation reduces the ischemia causing the angina.
Usual Dose: Sublingually, as needed, 0.4mg, repeated every 5 minutes for up to three doses. If that
dosage is ineffective, the patient should call “911" immediately. For prevention of chronic stable angina,
oral capsules of 2.5-6.5mg 3 to 4 times a day are used, or a topical patch 0.2-0.4mg/hour during waking
hours
Side Effects: Headache is the most common side effect of nitroglycerin use. Burning or tingling in mouth,
dizziness, flushing, headache, heavy sweating, lightheadedness, nausea, pale skin, vomiting.
Dental Considerations: Monitor vital signs every appointment due to cardiovascular side effects,
especially orthostatic hypotension. Stress is a main inducer of chronic stable angina, so ensure that
patient's nitroglycerin is easily available if angina occurs. Short appointments and a stress reduction
protocol may be required.
Generic Name: Nitrous Oxide
Use: as a very mild anesthetic with analgesic properties during dental procedures
Mechanism of Action: While in use since the 19th century, the mechanism of action for nitrous oxide is
unknown. It does have an effect on GABA receptors. Incapable of reaching safe surgical anesthesia with
nitrous oxide. The agent does stimulate the body’s release of endorphins, promoting pain relief during
dental procedures.
Usual Dose: Varies with patient age, physical condition, nature of surgery, and other drugs being used by
the patient.
Side Effects: The biggest concern with the use of nitrous oxide is the potential for hypoxia. Shivering or
trembling, blurred or double vision, dizziness, lightheadedness, or drowsiness; headache; mood or mental
changes; nausea (mild) or vomiting
Dental Considerations: nausea; the patient should also be able to communicate with you if hypoxia
begins to develop
Generic Name: Omeprazole (Prilosec)
Brand Names: Prilosec
Mechanism of action: A long-acting proton pump inhibitor that inhibits hydrogen ion transport into
gastric lumen. It doesn’t stop acid production by the cells; it prevents its release.
Usual Dose: 20mg per day, with some unapproved “pH rebalancing” protocols promoting use up to
120mg three times a day
Side Effects: headache, diarrhea, abdominal pain, nausea; long term use usually results in the patient
being placed on digestive enzymes to help maintain basic gastrointestinal function
Dental Considerations: some xerostomia
Generic Name: Penicillin
Brand Name: V Cillin K, Veetids
Uses: a bactericidal antibiotic to treat infections caused by bacteria
Mechanism of action: binds to bacterial cell wall, inhibiting bacterial cell wall synthesis
Usual Dose: 250-500mg four times daily
Side Effects: gastrointestinal disturbances (mild diarrhea, nausea, or vomiting), headache, oral or vaginal
candidiasis, generalized rash
Dental Considerations: Allergies occur in 5% of the population. Take precautions regarding allergy to
medication
Generic Name: Phenobarbital
Brand name: Luminal (not currently available under this name; mentioned here for historical reference
only)
Use: Antiseizure and (rarely) antianxiety agent
Mechanism of Action: a barbiturate with CNS depressive actions that raise the seizure threshold
Usual Dose: Varies, based on condition and duration of treatment. Antiseizure doses range from 30-
60mg once to four times daily.
Side Effects: Drowsiness, headache, dizziness, depression, excitement, upset stomach, and vomiting.
Dental Considerations: Rarely, some gingival hyperplasia. CNS depression may affect response to
general anesthesia or use of nitrous oxide. If patient is developing signs of porphyria, clotting factors
may be affected, with increased bleeding possible during procedures.
Generic Name: Phenylephrine
Brand Names: NeoSynephrine
Use: vasoconstrictive agent, used occasionally as an injection after surgery to increase blood pressure,
more commonly as a nasal spray to reduce congestion
Mechanism of action: a sympathomimetic (adrenergic) agent acting upon vascular smooth muscle. Usual
Dose: every 4 hours as a nasal spray
Side Effects: transient burning or stinging
Dental Considerations: patients with significant nasal congestion may complicate nasal administration of
nitrous oxide/ oxygen sedation
Generic Name: Phenytoin
Brand name: Dilantin
Use: Antiseizure drug, occasionally used as a cardiac antiarrhythmic agent
Mechanism of Action: research suggests that its main mechanism is to block frequency, use and voltage
dependent neuronal sodium channels and therefore limit repetitive firing of action potentials. This can
mute the action that can precipitate a seizure.
Usual Dose: 100mg, three to four times per day.
Side Effects: Gingival Hyperplasia, dizziness and CNS depression, nausea, vomiting, constipation, liver
damage
Dental Considerations: phenytoin is heavily associated with gingival hyperplasia, with the anterior labial
surfaces of the maxillary and mandibular gingiva most often affected
Generic Name: Pilocarpine
Brand Names: Salagen (oral), Isopto-Carpine (ophthalmic)
Uses: Treat dry mouth associated with radiation from cancer or Sjogren syndrome
Mechanism of Action: Cholinergic agent, increases secretion of saliva from salivary glands
Usual Dose: 5mg three to four times a day over a 12 week period
Side Effects: Chills, dizziness, flushing, frequent urination, nausea, runny nose, sweating, vision changes,
weakness
Dental Considerations: Assess salivary flow as a factor in dental caries, periodontal disease, and
candidiasis. Monitor vital signs every appointment due to cardiovascular side effects.
Generic Name: Pimoline
Brand Name: Cylert
Use(s): used to treat attention-deficit hyperactivity disorder (ADHD). A controlled substance.
Mechanism of Action: Although studies indicate that pemoline may act in animals through dopaminergic
mechanisms, the exact mechanism and site of action of the drug in man is not known.
Usual Dose: 37.5mg daily. It may take 3-4 weeks for this medicine to reach its full effect
Side Effects: Difficulty sleeping or drowsiness, dizziness, headache, nausea, stomach pain, or loss of
appetite.
Dental Considerations: some mild gingival hyperplasia is possible with ADHD stimulants. Xerostomia is
also a possibility.
Generic Name: Pralidoxime
Brand Names: 2-PAM, protopam
Mechanism of action: organophosphates poison by inhibiting the enzyme cholinesterase. With
cholinesterase inhibited, acetylcholine levels rise, enhancing its SLUD response. Pralidoxime reverses
this action, and when combined with atropine, is part of the antidote to organophosphate or cholinergic
poisoning
Use: Generally combined with atropine and most effective within 36 hours of cholinergic or
organophosphate poisoning
Usual Dose: 30-50mg/kg either by intravenous therapy or intramuscular injection
Side Effects: blurred or double vision; difficulty in speaking; difficult or rapid breathing; dizziness; fast
heartbeat; muscle stiffness or weakness; nausea
Dental Considerations: can cause swelling of lips, tongue, or throat which could lead to a choking
feeling
Generic Name: Prazosin
Brand Name: Minipres
Uses: Hypertension and benign prostatic hyperplasia (BPH)
Mechanism of Action: Alpha-adrenergic blocking agent, thought cause blood vessels and muscles around
urethra to relax
Usual Dose: 1mg two to three times daily
Side Effects: Constipation, depression, xerostomia, flushing, frequent urination, headache, nasal
congestion
Dental Considerations: Xerostomia and orthostatic hypotension
Generic Name: Procaine
Brand Names: Novocain
Use: Local anesthesic
Mechanism of action: causes a reversible blockade of nerve conduction by decreasing nerve membrane
permeability to sodium
Usual Dose: rarely used
Side Effects: allergic reaction; chest pain; dizziness or drowsiness; anxiety or restlessness; nausea or
vomiting; trembling, shaking or seizures; high level of allergies associated with procaine
Dental Considerations: rarely used; high rates of allergy. To the general public, however, “novocain” is
what all local anesthetics are. If a patient states an allergy to “novocain,” it is a signal to explore the
specific nature of the allergy more carefully.
Generic Name: Propranolol
Brand Names: Inderal
Uses: Treat high blood pressure or atrial fibrillation, decrease angina, prevent migraines, and decrease
risk of death after a first heart attack
Mechanism of Action: Prototypical beta-blocker -- note the “-olol” suffix. Beta-adrenergic blockade
slows the heart and reduces blood pressure
Usual Dose: 20-320mg per day, in divided doses or single sustained release preparations
Side Effects: Dizziness, drowsiness, lightheadedness, fatigue, feeling cold in the extremities.
Dental Considerations: Orthostatic hypotension fairly common with beta blocking agents. Some
xerostomia possible.
Generic Name: Rivastigmine
Brand Name: Exelon
Uses: Slows the progression of symptoms of Alzheimer's disease.
Mechanism of action: A cholinesterase inhibitor increasing the concentration of acetylcholine at
cholinergic synapses and enhancing cholinergic function in the CNS.
Usual Dose: Initially, 1.5 mg twice daily, may increase at 2 week intervals to 3 mg then 4.5 mg and
finally 6 mg.
Side Effects: Nausea, vomiting, diarrhea, dizziness, headache, and anorexia.
Dental Considerations: Determine why patient is taking drug. Monitor vital signs at every appointment.
Use precaution if sedation or general anesthesia is required; risk of hypotensive episode. May have
increased risk of infection, increased bleeding and poor healing.
Generic Name: Scopolamine
Brand Names: Transderm-Scop (topical patch)
Uses: preventing nausea and vomiting associated with motion sickness
Mechanism of action: an anticholinergic that reduces excitability of labyrinthine receptors, depressing
conduction in the vestibular cerebellar pathway.
Usual Dose: 1 system q72h.
Side Effects: dry mouth, somnolence, and blurred vision.
Dental Considerations: Avoid dental light in patient's eyes; offer darker glasses for patient comfort.
Caution patients about driving or performing other tasks requiring mental alertness.
Generic Name: Scopolamine
Brand Names: Scopace, Maldemar, Transderm Scop
Uses: Treat certain muscle problems, certain stomach or intestinal problems, and prevent nausea or
vomiting associated with motion sickness
Mechanism of Action: Anticholinergic agent, decreses transmission of certain nerve impulses to muscles
and in vomiting center of brain
Usual Dose: .4 to .9 mg as needed
Side Effects: Blurred vision, dizziness, dry mouth, drowsiness, mood or mental changes
Dental Considerations: Xerostomia is very common. Xerophthalmia may sensitize patient to dental
lights; offer dark glassed for patient comfort.
Generic Name: Tacrine
Brand Names: Cognex
Uses: Slows the progression of Alzheimer's disease.
Mechanism of action: A cholinesterase inhibitor that inhibits the enzyme acetylcholinesterase, thus
increasing the concentration of acetylcholine at cholinergic synapses and enhancing cholinergic function
in the CNS.
Usual Doses: Initially, 10 mg 4 times daily for 6 weeks, then 20 mg 4 times daily for 6 weeks, then 30
mg 4 times daily for 12 weeks.
Side Effects: Headache, nausea, vomiting, diarrhea, dizziness.
Dental Considerations:
Side Effects: Enhanced SLUD response, dizziness, headache, confusion, anxiety, skin rash, increased
sweating, rhinitis, nausea, vomiting, diarrhea, abdominal pain, constipation, urinary incontinence,
myalgia.
Dental Considerations: Increased salivation, unpredictable effect on blood pressure
Generic Name: Testosterone
Common Brand Names: Androderm (topical patch), Depo-testosterone (injection)
Uses: Testosterone supplement for men
Mechanism of Action: Promotes growth and development of male reproductive organs, maintains
secondary sex characteristics, increases protein anabolism
Usual Dose: 2.5mg to 5mg via topical patch; 50mg to 400mg every two to four weeks (injection)
Side Effects: Acne, bitter taste, change in sex drive, fatigue, gum irritation and pain, hair loss, headache,
personality changes and increase in aggression
Dental Considerations: Gum or mouth irritation, gum pain, tenderness, or swelling
Generic Name: Tetracycline
Brand Names: Achromycin V, Sumycin.
Use: bacteriostatic antibiotic
Mechanism of Action: Inhibits bacterial protein synthesis.
Usual Dose: 250-500mg four times daily, on an empty stomach.
Side Effects: Photosensitivity, diarrhea, nausea, vomiting, stomatitis, black hairy tongue, staining of teeth
during formation.
Dental Considerations: Stomatitis, black hairy tongue, permanent discoloration of teeth may be caused
during tooth development. Enamel hypoplasia has also been reported.
Generic Name: Thalidomide
Brand Names: Thalomid
Uses: Treating skin inflammation in patients with erythema nodosum leprosum and patients with certain
types of cancers
Mechanism of Action: Possesses immunomodulatory, anti-inflammatory properties; action not fully
understood. In cancer patients, it appears to increase certain natural substances (necrotic factors) that
help to kill cancer cells.
Usual Dose: 50mg to 400mg per day after evening meal
Side Effects: Constipation, diarrhea, dizziness, headache, nausea, trouble sleeping, weakness; birth
defects among children of either parent using thalidomide
Dental Considerations: Fluorides may increase patient nausea; immunocompromised patients are more
prone to oral herpes infections, xerostomia, parotid gland enlargement
Generic Name: Thyroid
Brand Names: Armour Thyroid, Thyroid Strong
Use: thyroid supplement to treat hypothyroidism
Mechanism of action: a natural hormone derived from animal sources, usually beef or pork, that is
involved in normal metabolism, growth, and development. Possesses catabolic and anabolic effects.
Provides both levothyroxine and liothyronine hormones (these are available as synthetic derivatives on
their own)
Usual Dose: 30-120mg daily (dessicated thyroid)
Side Effects: allergic reaction; nervousness; headache; insomnia; changed in appetite; leg cramps; fever
Dental Considerations: increased nervousness, excitability, sweating, or tachycardia may indicate
uncontrolled hyperthyroidism or a dose of medication that is too high. Uncontrolled patients should be
referred for medical treatment.
Generic Name: Valproic acid
Brand Names: Depakene, Depakene, Depakote, Depakote ER.
Mechanism of Action: Believed to work by increasing brain levels of gamma-aminobutyric acid (GABA)
Usual Dose: 250-500mg three to four times daily
Use: Initially for seizure disorders, now additionally used for migraine headaches and bipolar disorders
Side Effects: Tremor, somnolence, dizziness, insomnia, blurred vision, taste change, nausea, vomiting,
diarrhea, glossitis, periodontal abscess, dry mouth, stomatitis, tooth disorders.
Dental Considerations: Some gingival hyperplasia possible. Coagulation changes may increase gingival
bleeding. Taste change, xerostomia, and stomatitis possible.
Generic Name: Warfarin
Brand Names: Coumadin
Uses: Treating or preventing blood clots, reduce the risk of heart attack or stroke
Mechanism of Action: Interferes with hepatic synthesis of vitamin K-dependent clotting factors, resulting
in depletion of clotting factors II, VII, IX, and X.
Usual Dose: 1mg to 10mg daily
Side Effects: Bloody stools, blood in urine, shortness of breath, unusual bleeding gums, vision problems
Dental Considerations: Consider local hemostasis measures to prevent excessive bleeding. Increase in
bleeding with IM injections may occur.
Generic Name: Zanamivir
Brand Name: Relenza.
Mechanism of Action: antiviral drug that appears to inhibit the influenza virus enzyme neuraminidase,
which is essential for viral replication.
Usual Dose: two inhalations twice a day (one 5 mg blister per inhalation) for 5 days
Side Effects: allergy; headache; dizziness; nausea; vomiting; ear, nose, or throat infection, cough, or
respiratory problems especially in people with asthma
Dental Considerations: acute influenza patients are unlikely to be seen in the dental office except for
dental emergencies, some patients may exhibit rare signs of facial edema
With appreciation to Jennifer Belen, Stephanie Cameron, Gina “Gigglecookie” Cutsforth, Jen DeKarske, Carley Dettl, BonnieFlora, Veronika Golubeva-Stiles, Annie Muneer, Shereesha Nandimandalam, Brianne Neelis, HeatherSarnac, Heather Schoiber, and Kristi Tarrant for their assistance in compiling the monographs in thisappendix.

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