Commonly Prescribed Prescriptions Comment: Most dental practitioners will prescribe a relative small number of prescription medications. It is the responsibility of the dentist to be familiar with all medications they are using in their practice, including side effects, patient instructions, drug interactions, etc. It is strongly recommended you have immediate access to a good dental drug reference book. To have the most complete listing of information, you may also wish to ask your local pharmacist for a drug insert on each medication prescribed. Keep it in a reference notebook in your dental practice. (Most references, for example Lexi-Comp guides, have good coverage, but it may not be the most complete information. For a specific question concerning a drug side effect or interaction, the drug manufacturer can be considered a primary source of information.) If patients are systemically unwell, have difficulty swallowing, and/or there is a threat to their airway, this is a true dental emergency. Referral for immediate medical care is needed in a patient with a threatened airway.
Common dental indications: 1) Treatment of acute dental infections or for periodontal infections 2) Treatment for dental abscess/infection 3) Prophylaxis in patients at risk of developing infective endocarditis (IE) http://www.ada.org/public/topics/antibiotics.asp 4) Prophylaxis in patients with compromised host defense mechanisms
Need for pre medication for prophylaxis use: 1) Amoxicillin, if no allergies (DOC) 2) Clindamycin, Cephalexin or Cefadroxil, Azithromycin or Clarithromycin as second line (Refer to American Heart Association Guidelines;2007) Infective endocarditis prophylaxis: Amoxicillin 500mg
Disp: four (four) Sig: take four caps po 1hr prior to dental appointment for pre med Peds: 50mg/kg 1-hr prior Clindamycin 150mg “Cleocin”
Disp: #4 (four) Sig: Take 4 caps po 1hr prior to dental appt for pre med Peds 20mg/kg 1 hr prior
Disp: #4 (four) Sig: 4 tab 1hr prior to dental appt for pre med Peds 50mg/kg 1 hr prior Azithromycin 250mg “Zithromax”
Sig: 2 tab po 1hr prior to dental appointment for pre med Peds: 15mg/kg1hr prior
Antibiotics Classification Antimicrobials:
1) Inhibitors of Cell wall synthesis (peptidoglycan synthesis) Beta Lactams Penicillin, Cephalosporins, Carbapenems, Vancomycin
50S subunit Macrolides
Erythromycin, Azithromycin, Chloramphenicol, clindamycin
30S subunit Tetracycline (Doxycycline)
Aminoglycosides: Gentamicin, Tobramycin, Amikacin
4) DNA replication involves topisomerases
Category: Amebicide, Antibiotic, Anaerobic. Topical-Antiprotozoal.
Nystatin, Clotrimazole, Ketoconazole
8) Antivirals Comment: Please note that oral contraceptives efficacy may be reduced with usage of any antibiotic especially the broad-spectrum antibiotics. Please inform your patient if taking an oral contraceptive, that another method of birth control is needed for that cycle. We do not use bactericidal and bacteriostatic drugs together as a general rule. Patients need to be informed to take full round of prescribed antibiotics to prevent resistance formation (i.e. do not discontinue antibiotic when you start to feel good) unless otherwise instructed to do so. Also they should be informed to take the medication as close to the dosing schedule as possible to prevent the effective blood level from falling which could result in resistant strains of bacteria forming. Allergic and hypersensitivity reactions can occur with any of our antibiotics, check your patient’s medical history prior to prescribing. Beta Lactams
Inhibits cell wall synthesis. Bactericidal agent, broad spectrum.
Uses: Bacterial endocarditis prophylaxis DOC Many Gram + and more gram - organisms then penicillin. Does not cross BBB, unless meningitis present. Side effects: 15% hypersensitivity Uticaria and flushing. 0.005% Anaphylactic shock. Diarrhea, 3 to34%, nausea, vomiting and cramps. Seizure-risk higher in renal failure patients and with high doses. Pseudomembranous colitis. Prolonged use oral candidiasis, May decrease oral contraceptive efficiency. Jarisch-Herxheimer reaction – not true allergic reaction due to protein released by infecting organism (as seen in spirochete infections). Produces characteristic rash when used on patients with infectious mononucleosis (not true allergy). Stevens-Johnson syndrome. Also comes with Clavulanic acid: “Augmentin” used to increase plasma levels of drug. Do not double dose first dose of amoxicillin/clavulanic. Note: Clavulanic acid has no antimicrobial activity; it will increase half-life of amoxicillin by inhibiting beta lactamase.
Penicillin VK 500mg “Pen VK 500mg”
Caused by aerobic gram positive cocci and anaerobes. Bacteriocidal
Uses: DOC in treating common orofacial infections. Also used for
cellulitis, periapical abscess, periodontal abscess, acute suppurative pulpitis, oronasal fistula, pericoronitis, osteitis. Side eff: 15% hypersensitivity. 0.005% Anaphylactic shock. Diarrhea, N/V, seizure (rapid IV infusion)., acute interstitial nephritis, convulsions. Prolonged usage may develop candidiasis. Spect: Gram + cooci, gram – rods few, narrow spectrum.
Cephalexin 500mg “Keflex”
1st generation Cephalosporin, beta lactam
MOA: Cell wall synthesis inhibition, and does not
BBB. Narrower spectrum of activity compared to
Uses: An alternate antibiotic to treat orofacial infections in patients allergic to penicillins. Susceptible bacteria including aerobic gram + bacteria and anaerobes. Side effects: Cross sensitivity of penicillin-allergic patients. Positive Combs reaction, potentially nephrotoxic. Bleeding has occurred in debilitated and elderly patients - hypoprothombienemia, thrombocytopenia. GI Disturbances, diarrhea. Pseudomembranous colitis- not as common. Also, infective endocarditis prophylaxis. (see above dosage chart). May need to modify dose in renal failure patient
All drugs that bind at 50 S subunit can antagonize each other.
50 S Subunit-MACROLIDES Erythromycin /
MOA: Binds 50 S ribosomal subunit, inhibiting
Protein synethesis. Bacteriostatic,alternative to penicillin for
gram positives primariliy,patients allergic to PCN. Many bacteria
Sig: one cap q 6 hr for dental infection
Rapidly develop resistance. Metabolizm by Cytochrome P450, caution with other drugs metabolized in same way-may effect drug actions. Examples: Protease inhibitors –Ritonavir. Do not use with Astemizole or Terfenadine “seldane” or Cisapride “Propulsid”- May have fatal acute cardiotoxicity.Prolonged QT segments, Use caution in Fentanyl class of narcotics, use caution with benzodiazepines. And many others. Side effects: GI-epigastric distress-limiting factor.Oral Candidiasis.Cholestatic hepatitis esp estolate form. Hypersensitivity possible, rare.
Given in many base forms: Phosphate, estolate, ethylsuccinate
Recheck dosages as they change depending on salt used.
Estolate salt contraindicated in pregnancy. Bacteriostatic. Take with food or milk if GI symptoms. Caution usage in impaired hepatic function.
Azithromycin 250mg “Zithromax”
Macrolide, MOA: binds to 50S subunit prohibiting
protein synthesis. Fairly broad spectrum
Spect: Gram + aerobes/anaerobes, some gram -
Includes H.pylori, and H. influenza, chlamydia, Mycoplasma, B.
Peds: 15mg/kg/1hr prior Disp: #7 (seven) Sig: 2 tab now, 1 tab every day for 5 Days until all taken for dental infection
pertussis, many others. Alternate antibiotic if amoxicillin cannot be used in the treatment of common orofacial infections caused by
aerobic gram-positive cocci and susceptible anaerobes. Infective endocarditisprophylaxis
Side Eff: GI Disturbance, N/V, headache, Pseudomembranous colitis. Note: Works well for oral infections, but better for respiratory infections for osteomyelitis and purulent osteitis. Contraindication: hepatic impairment Antacids containing aluminum and magnesium will decrease absorption by 24%. Should be taken 2 hrs after or before antibiotic. Do not take with meals. Take 1 hr before or 2 hrs aftermeals.
Clindamycin 150mg ”Cleocin”
Binds 50 S ribosomal subunit, inhibiting
protein synthesis. Fairly broad spectrum. Unique
alternate antibiotic when amoxicillin cannot be used for SBE coverage. An alternate to penicillin and erythromycin for treating orofacial infections. Spect: Gram + aerobes/anaerobes and anaerobic gram – rods. Includes B. Fragilis. Does not cross BBB. Notes: Clostridium difficile overgrowth - (treatment DOC metroniadazole). Can get pseudomembrous colitis with as little as one dose, discontinue use if diarrhea develops especially if blood or mucous in stool. Side effects: N/V., Rashes, Gastrointestinal. Studies show drug levels in bone can reach nearly that of plasma. Contraindications: hypersensitivity, caution liver disease, previous pseudomembrous colitis. Includes renal toxicity with gentamicin. May be taken with food; food may delay peak concentrations. 30 S Subunit Tetracycline HCL 500mg
Inhibits tRNA binding to ribosome inhibiting
protein synthesis. Broad gram + and gram –. Broad spectrum,
bacteriostatic, a lot of bacterial resistance develops Good for Rickettsia, Used in perio for Actinobacillus actinomycetemcomitans (A.a). (UMKC- perio department uses Tetracyline 250mg QID for 10-21 days. Longer time frame best, and some sources recommend 21-28 days to eradicate A.a.). Readily crosses BBB Side effects: Superinfection, GI upset, photosensitivity, allergic reactions, Pseudomembranous Colitis. Not for use during pregnancy or with children. Will cause discoloration of teeth and enamel hypoplasia in children and retard skeletal growth and normal bone growth. Do not take with milk or milk products. Do not take with antacids, iron. Take on empty stomach 1 hour before meals or 2 hoursafter.
MOA: Inhibits tRNA binding to 30 S ribosome
(very similar to tetracycline structure)
Spect: Broad gram + and gram - Bacteriostatic
Good for Rickettsia, Used in perio for and for actinomycosis. Can cross BBB. (UMKC perio -Doxycline 50mg b.i.d. for 10-21 days, longer time frame best. And some individuals give 100mg BID instead. Some sources recommend 21-28 days eradicate A.a.) Fifth drug of choice for Odontogenic infections behind penicillins (amoxillin included) , cephalosporins, erythromycin, and clindamycin. Side effects: Superinfection, GI upset, photosensitivity, allergic reaction, Pseudomembranous Colitis. Not for use in pregnancy or in children under 8 years of age. Will cause discoloration of teeth and enamel hypoplasia in children and retard skeletal growth and normal bone growth. Do not take with milk or milk products. Do not take with antacids, iron. Take on empty stomach 1 hour before meals or 2 hours after.
Metronidozole 250mg “Flagyl”
Category: Amebicide, Antibiotic, Anaerobic. Topical-Antiprotozoal. MOA: Cause DNA Strand breaks and is
electron acceptor, carcinogenic in rodents.
Spect: Anaerobes, Trichomonas, Bacteroide, Fusobacterium.
Good for ANUG, NUP, or as second drug for periodontal disease. Dental: treatment of oral soft tissue infections due to anaerobic bacteria including all anaerobic cocci, anaerobic gram - bacilli (Bacteroides) and gram + spore forming bacilli (Clostridium). Useful as single agt or in combination with amoxicillin, augmentin or ciprofloxacin in treatment of periodontitis associated with Actinobacillus actinomycetemcomitans (A.a.) Used for Pseudomembranous colitis Side effect: Disulfiram (Antabuse reaction), headache, flushing, tachycardia, Candida, Superinfections, possible aplastic anemia. 1% of patients may experience dry mouth and metallic taste. Dizziness. Loss of appetite. Precautions: In patients with liver impairment, blood dsycrasias, history of seizures, congestive heart patients or other sodium retaining states. Dosage adjustment in severe liver disease, severe renal disease, and CNS disease. Food has no effect on absorption, but delays rate and decreases maximum concentration. However, may take withfood if GI upset.
Chlorhexidine Gluconate 0.12% “Peridex” MOA: A biguanide that osmotically disrupts membrane Disp: #1 – 16oz bottle
Many gram +, Gram-, Fac Anaerobes, Fac Aerobes, Yeast.
Uses: Antibacterial dental rinse. Side effect: Staining of teeth and plaque accumulation. Change in taste, tongue irritation and staining. Nasal congestion and dyspnea sensation. Co-precipitates with nystatin. Do not use both simultaneously. Swelling of face has been reported. High alcohol content may sting oral ulcers. Antifungals Clortrimazole 10mg troches
MOA: binds to phospholipids in fungal cell membrane
“Gyne-Lotrimin” “Mycelex” Use: dental for susceptible fungal infections including
Sig: 1 troche 5 times per day until gone
Side effects: Can elevate liver enzymes, GI disturbances, N/V, local mild burning or irritation.
Fluconazol 100mg “Diflucan”
MOA: Interferes with Cytochrome P-450 activity and inhibiting
Use: dental for susceptible fungal infections including
Side effects: 1 to 10% headache, Skin rash, N/V, abdominal pain, and diarrhea. May increase phenytoin and warfarin levels.
Ketoconazole Cream 2% “Nizoral”
Use: Treatment of susceptible fungal infections in the oral
cavity including candidasis, oral thrush, and chronic
Comment: Codeine products, as well as other narcotic analgesics, are recommended for only acute dosing in dentistry. (If patient has pain that continues past the acute stage, patient needs to be seen again.) The most common side effect you will see is nausea, followed by sedation and constipation. Ibuprofen is a non-narcotic analgesic ( and considered to be drug of choice for moderate dental analgesia for dental applications and can be used for longer coverage of pain. (However, always limit analgesic medications to the relief of pain period only. This is an NSAID and hypersensitivity and GI adverse effects limit usage) Adequate analgesic relief is very dependent on severity of pain and on patient weight. Please recognize a 90 pound sixty year old woman with a peridontally involved tooth extraction has very different analgesic needs from a 250 pound twenty-five year old male with a bony impacted extraction. Our nighttime emergency coverage team and your patients, implore you to adequately cover necessary analgesic needs. The best pain relief is to address the infection that is causing the pain. (i.e. Tooth extraction, root canal therapy, drain of severely infected area with swelling) ================== =============================================================================
Combinations Analgesics low to moderate pain Class IV
Darvocet N 100mg
650mg acetaminophen (caution liver disease)
Contraindication: Hypersensitivity, G-6PD Deficiency
Max dose 600mg mg Propoxphene/day, fatalities possible Use very limited by itself; Mild pain. Not best selection. ASA by itself may be better. Should be taken on empty stomach; do not take with alcohol. Additive CNS depression with other medications! Side effects: psychoses and hallucinations at high doses, especially with EtOH. Class IV. Cigarette smoking can decrease analgesia. Caution: drug interactions with other drugs metabolized in liver!
Acetaminophen, OTC “Tylenol”
Analgesic, Antipyretic, but no anti-inflammatory effect.
Contraindication: Hypersensitivity, G-6PD Deficiency
Used treatment of post op dental pain. No dental effects or complications. Can be used as alternative drug for analgesia if patient has aspirin or NSAID hypersensitivity.
Contraindicated with hypersensitivity to ASA.
Analgesic, Antipyretic, Anti inflammatory, anticoagulant.
Good drug, but many adverse reactions limits usage today.
Take with food or water to avoid GI effects, however this will decrease absorption. Contraindication: Peds patient, esp. if chickenpox presence or influenza symptoms-due to REYES syndrome. Side effects: GI distress, Nausea, vomiting, asthma ppt,Salicylism, increased bleeding. Contraind.: Ulcers, asthma, anticoag, EtOH use. Caution with diabetes, renal disease, liver disease and elderly. As much as 60% can develop peptic ulceration and/or hemorrhage asympt. Note: Discontinue use of aspirin one week prior to dental surgery, however, if patient is using for anti-thrombin effect, special consideration-check with physician.
Moderate pain Motrin 400mg
Ibuprofen 400mg, Not a class prescription (NSAID)
MOA Decr. prostaglandin synthesis: Cyclooxygenase inhibitor,
Non narcotic - Non aspirin, analgesic. Excellent non-narcotic analgesic; good pain coverage for moderate pain in dental.
Dosing 400-800mg q 4-6 hr Maximum dose 3200mg/day Side effects: may develop dry mouth GI upset, headache, indigestion, nausea. Take with food if occurs. Decreases platelet aggregation. Nephrotoxicity. Caution in elderly-as much as 60% can develop peptic ulceration and/or hemorrhage asympt. Contraindicated in Pregnancy unless OK’d by OB/GYN. Take with food or water to avoid GI effects, however this will decrease absorption. Preoperative use of ibuprofen at dose of 400-600mg q 6 hr, 24 hours prior to appt. decreases postoperative edema and hastens healing time. Caution: drug interactions with other drugs metabolized in liver!
Contra: pat with hypersensitivity acet or codeine
Dosing: 60mg q 4 hr for analgesia (30mg no better then placebo) Class III-lower addiction potential.
Adv rxns: 1% dry mouth, 10% Light-headedness, Dizziness, CNS sedation, nausea. 1-10% gastrointestinal, constipation. May be taken with food. Caution in liver disease. Widely used in peds dentistry (see peds med below) See acetaminophen notes. Suspension: Acetaminophen 120mg/codeine 12mg/5ml
Empirin #3 Aspirin 325mg/codeine 30mg Class III
Contraindications: hypersensitivity to ASA or Codeine.
Sig: 1 tab q 4hr prn pain Lower addiction potential (See ASA notes and Tylenol #3 notes
for codeine) Side effects: Dry mouth, hypotension, fatigue, drowsiness, dizziness, GI symptoms, N/V, Constipation. Fiorinal w/ codeine
Butalital 50mg, caffeine 40mg, aspirin 325mg, and codeine
Phospate 30mg. Contraindication: hypersensitivity.
Side effects: Dry mouth, hypotension, fatigue, drowsiness, dizziness, GI symptoms, N/V, Constipation. CNS: “jitters” confusion, headache. Caution with renal, pulmonary, hepatic patients. Seizures threshold may be lowered at high doses. See aspirin notes. Class III Moderate to severe pain- should be restricted to occasional Rx not to be overused. Best to address source of dental pain. Side Effects/negatives: Addiction potential and drowsiness
Moderate to severe Vicodin 5
5.0 mg hydrocodone, Class III
Use: Used extensively for moderate to severe dental pain
Greater Addiction Potential
Contraindication: hypersensitivity. G-6-PD deficiency.
(Vicodin ES; Acet 750mg/ hydrocod 7.5mg)
(Vicoprofen; Ibuprofen 200mg, hydrocodone 7.5mg)
[Consider this plus one OTC Ibuprofen 200mg]
Side effects: N/V, constipation, dizziness, sedation. Dry mouth, potentiates other CNS depression effects. i.e. Tricylic antidepressants, MAO inhibitors, other narcotics, antipyschotics, antianxiety agents, or other CNS depressants. Onset is 10 to 20 minutes Severe The degree of abuse of these medications may limit your prescribing to only a rare usage. Class II Demerol 50mg
Narcotic agonist, Meperidine 50mg, class II Excellent IM/IV med, oral efficacy erratic
Better oral choices for dental pain. Do not use with MAOI’s – hypertension risk. Must be off for 14 days. Side effects: hypotension, fatigue, drowsiness, dizziness, GI symptoms, N/V, constipation. Caution with renal, pulmonary, hepatic patients. Seizures threshold may be lowered at high doses. Contraindication: hypersensitivity. Percocet 5
Narcotic agonist, acetaminophen 325mg, Oxycodeine 5mg
Greater addiction potentialClass II
significant euphoria. Relief of moderately severe pain
Acetaminophen 325mg/oxycodone HCL 5.0mg Side effects: 1-10% dry mouth, 10% drowsiness, dizziness, sedation. Contraindicated. Known hypersensitivity. Not recommended in peds patients. Percodan Greater addiction potentialClass II
Significant euphoria. Relief of moderately severe pain
Side effects: 1-10% dry mouth, 10% drowsiness
Dizziness, sedation. Elderly at high risk for NSAID.
Usage-see previous note. Contraindications: Known hypersensitivity. Not recommended in peds patients
Gel-Kam 0.4% , OTC
Brush, expectorate excess, do not rinse.
Disp: #1-20oz tube (Long term use of acidulated fluorides has been
associated with enamel demineralization and Damage to porcelain crowns and composite restorations)
Prevident 1.1% NaF Gel
Neutral ph. Used for topical adjuvant to control recurrent caries
decalcified enamel. Neutral ph fluorides are preferred in patients
with oral mucositis to reduce tissue irritation. (Long term use of acidulated fluorides has been associated with enamel demineralization and damage to porcelain crowns and composite restorations.) Do not drink or eat for 30 minutes. Do not administer with milk.
Prevident 5000+ 1.1 % NaF Cream This is a toothpaste and fluoride especially Disp: #1-1.8oz tube
for patients who do not want an extra step of
applying the fluoride. More expensive than using the fluoride gel.
Do not drink or eat for 30 minutes. Do not administer with milk
Bupropion SR 150mg “Zyban”
MOA not fully understood, weak blocker of
Serotonin, noreipnephrine re-uptake, and inhibits dopamine.
Side effect: dry mouth, N/V, confusion, agitation,
insomnia, syncope, drowsiness, fatigue, headache, impotence
Contraindication in patients with seizure disorder, MAO Nicotine Inhaler
Aid to smoking cessation while participating in a behavioral
modification program under dental or medical supervision
Usually 6 to 16 cartridges per day, best effect achieved by frequent continuous puffing (20 minutes) recommended duration of treatment is 3 months, after which the patient may be weaned from the inhaler by gradual reduction over 6 to 12 weeks.
Nicotine Nasal Spray
1-2 sprays/hr, do not exceed more than 5 doses (10 sprays) per hour; each dose has 1 mg of nicotine. Warning: a dose of 40mg or more can cause fatalities.
Side effects: 10% patients chewing gum form experience excessive salivation, mouth, or throat soreness.
Other: tachycardia, headache, N/V salivation, belching, increased appetite, hiccups, insomnia, dizziness, nervousness. Hoarseness, atrial fibrillation, itching, hypersensitivity.
Lidex ointment 0.05%
Fluocinolone 0.05%, Corticosteroids, topical (gel also available)
High potency. Used for oral nonviral soft tissue ulcerations or
Adverse reactions: Local burning and irritation, allergic dermatitis. Misc. secondary infection, acne. Hypopigmentation. Patient should only apply thin layer
Antianxiety agent Short acting Triazolam 0.25mg “Halicon”
Benzodiazepine class IV MOA: CNS depressant
Side effect: drowsiness, headache, dizziness., N/V, confusion
xerostomia Contra indication narrow angle glacoma., hypersensitivity, Additive CNS depressant effects with drugs
that also have CNS depression, Do not use elderly or seizure
And one tab 30 min prior to appt patients. Decreaseed effects seen in patients on drugs metabolized
in liver. (phenytoin, phenobarbital) increased effect in cimetidime and erythromycin. Onset 30minute, duration 6 to 7 hours.
Patient should not drive with medication on board. (Lorazepam 1mg–Ativan also could be given similar duration.) PenicillinVK
Patients weighing more than 20kg dosage is 250-500mg q 6 hrs Patients weighing less than 20kg dosage is 50-100mg/kg q 6 hrs Supplied as 125, 250, or 500mg tabs or 125mg/5cc or 250mg/5cc suspension 7-10 days usual length of time for administration. Depends upon patient weight. Increased weight – use an increased dose. Example: PenVK 250mg tabs Disp: 28 tabs Sig: Take 1 tab qid til gone Also dispensed in liquid for those who cannot take pills Pen VK Oral Suspension (250mg/5cc) Disp: 140cc Sig: Take 1 tsp qid til gone If allergic to penicillin Erythromycin Patients weighing more than 20kg
Side effects: Patients may have diarrhea
doses QID. Clindamycin-Used for significant Infections and/or allergy to Penicillin Usual dosage 8-12 mg/kg/day in 3-4 Analgesics Pediatric UMKC
Usually suggest Children’s Tylenol or Children’s Motrin plain as per package insert. Rarely do we write a prescription for Tylenol with codeine elixir. If you do have that need:
1. Example for 3-6yr old child with negative
Tylenol elixir with codeine contains: 12mg codeine,
Side effect :If tired or lethargic in day
negative medical history, for Rx for 3 days. Tylenol with codeine elixir Disp: 120mls Sig: take 2 tsps q 6 hours prn pain ------------------------------------ 3. In a very young child or child who doesn’t weigh much i.e. < 15-20 kg you may want to use ½ tsp q 6 hour
HAND-ARM VIBRATION SYNDROME: A SYSTEMATIC REVIEW OF RISK FACTORS AND INTERVENTIONS Mark Boocock, Peter McNair and Peter Larmer Health and Rehabilitation Research Centre, Auckland University of Technology (AUT), Private Bag 92006, Auckland 1142, New Zealand ABSTRACT Hand-Arm Vibration Syndrome (HAVS) is an occupationally-related disease arising from prolonged and repeated exposure t
Page 2 of 17 JDDG manuscript proof How to run a an effective and efficient dermato- oncology unit. Short title: How to run a dermato-oncology unit Simone (S) van der Geer*, Hajo (H.A) Reijers**, Gertruud (G.A.M) Krekels*** For Peer Review Department of Dermatology, Rotterdam, the Netherlands. ** Eindhoven University of Technology, School of Industrial Engineering, Eindhoven, **