Your Pocket Size Dental Drug Reference Series [1 ed.] 9781607951612, 1607951614

Table of contents :
Cover
Your Pocket-Size Dental Drug Reference - 2012 Edition
Weight Equivalents
Foreward
Preface
Contents
I.Antibiotics & Antimicrobials
II.Antihistamines & Palliative Coating Agents
III.Topical Anesthetics, Chemical Cauterizers, and Keratolytic Agents
IV. Antifungals
V. Immunosuppressives, Occlusive Dressings & Compounds
VI. Antiviral Agents, Viral-Blocking Agents, Germicidals
VII. Muscle Relaxants
VIII. Antianxiety Agents for Stress Management
IX. Antidepressants
X. Analgesics
XI. Local Anesthetics
XII. Vasoactive Drugs
XIII. Antixerostomics & Fluoride Gels/Rinses
XIV. Tooth Desensitizers
XV. Hemostatic Agents (Topical and IV)
XVI. Burning Mouth Syndrome, Neuralgia, and Myofascial Pain
XVII. Nutrient Deficient and Supplement Therapy
XVIII. Taste and Smell Disorder Therapies
XIX. Miscellaneous Over-the-Counter Oral Rinses and Products to Relieve Mouth Pain
XX. Herbal & Non-herbal Remedies
XXI. Management of Patients Receiving Radiation or Chemotherapy
XXII. HIV Infection & AIDS
XXIII. Halitosis
XXIV. Prescription Requirements and Safe Writing Practices
References
Index

Citation preview

Your Pocket-Size Dental Drug Reference 2012 Edition

A Handbook of Commonly Used Dental Medications Useful in the Management of Oral Diseases and Conditions

by Michael A. Kahn, D.D.S. © 2012

People’s Medical Publishing House-USA 2 Enterprise Drive, Suite 509 Shelton, CT 06484 Tel: 203-402-0646 Fax: 203-402-0854 E-mail: [email protected] © 2012 PMPH-USA, Ltd. All rights reserved. Without limiting the rights under copyright reserved above, no part of this publication may be reproduced, stored in or introduced into a retrieval system, or transmitted, in any form or by any means (electronic, mechanical, photocopying, recording, or otherwise), without the prior written permission of the publisher. 11 12 13 14/PMPH/9 8 7 6 5 4 3 2 1 ISBN-13: 978-1-60795-161-2 ISBN-10: 1-60795-161-4 Printed in China by People’s Medical Publishing House Copyeditor/Typesetter: Spearhead Global, Inc. Cover Designer: Mary McKeon Library of Congress Cataloging-in-Publication Data Kahn, Michael A. Your pocket-size dental drug reference : a handbook of commonly used dental medications useful in the management of oral diseases and conditions / by Michael A. Kahn. — 2012 ed. p. ; cm. Includes bibliographical references and index. ISBN-13: 978-1-60795-161-2 ISBN-10: 1-60795-161-4 I. Title. [DNLM: 1. Pharmaceutical Preparations—Handbooks. 2. Dentistry— Handbooks. QV 39] 617.6⬘061—dc23 2012005636 Notice: The authors and publisher have made every effort to ensure that the patient care recommended herein, including choice of drugs and drug dosages, is in accord with the accepted standard and practice at the time of publication. However, since research and regulation constantly change clinical standards, the reader is urged to check the product information sheet included in the package of each drug, which includes recommended doses, warnings, and contraindications. This is particularly important with new or infrequently used drugs. Any treatment regimen, particularly one involving medication, involves inherent risk that must be weighed on a case-by-case basis against the benefits anticipated. The reader is cautioned that the purpose of this book is to inform and enlighten; the information contained herein is not intended as, and should not be employed as, a substitute for individual diagnosis and treatment.

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Metric System Weight kilogram = kg = 1000 gram gram = g = 1 gram milligram = mg = 0.001 gram microgram = μg = 0.001 milligram Volume liter = L = 1000 milliliters milliliter = ml = 0.001 liter Metric and Apothecary Equivalents Weight Equivalents—Approximate Metric Apothecary 1 mg 1/65 grain 65 mg 1 grain 1 32 mg /2 grain 324 mg 5 grains 1g 15.432 grains 31.103 g 1 ounce (oz) Volume Equivalents—Approximate Metric Apothecary >1.0 ml 16.23 minims 4.0 ml 1 fluid dram 30 ml 1 fluid ounce (oz) 480 ml 1 pint 960 ml 1 quart Household Equivalents—Approximate Utensil Volume 1 teaspoonful (tsp) 5 ml 1 tablespoonful (tbsp) 15 ml 1 teacupful 120 ml 1 tumbler glassful 240 ml Clark’s Rule child’s weight (lb) × adult dose = child’s dose 150

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Weight lb/kg Chart 1 kg = 2.2 lb Kilograms (kg) >10 20 25 30 35 40 45 50 55 60

Pounds (lb) 22 44 55 66 77 88 99 110 121 132

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FOREWORD This pocket-size booklet is a compilation of prescribed drugs and therapeutic regimens useful in the treatment of common oral diseases and conditions. Its content is not intended to be all-inclusive but is provided to give an overview of the pharmaceuticals available and the protocols that have been developed. The number of medications within each category has intentionally been limited so that the booklet may be conveniently placed in a clothing apparel pocket. Oral pathologists and other clinicians who have an interest in oral medicine have successfully used the specialized protocols listed; some regimens are off-label use. The author acknowledges that the same treatment objectives may be accomplished by many pharmacological and therapeutic approaches. Brand names are included for the convenience of identification. No advertisement or promotional support is accepted from any company or interest. The drugs are grouped according to their class of action or use for a specific condition. Every effort has been made to ensure that drug selection and dosage are in accordance with current recommendations and practice; however, in view of ongoing research, changes in governmental regulations, and new drug reactions, the clinician is urged to check the package insert or back label of each drug for any change in indication or dosage and for warnings and precautions. For any given patient, the drug, dosage, and administration may vary from the accepted norm, depending on the clinical situation. As with any therapeutic procedure, the clinician has the responsibility to determine whether there are any contraindications to the proposed therapy, be aware of the potential complications and side effects, and inform the patient of such possibilities. The following must always be considered for possible contraindications: medical history, pregnancy, nursing mothers, children, known hypersensitivities, the elderly or medically compromised, patients with impaired renal or hepatic function, concurrent medications, and full-disclosure labeling.

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PREFACE TO THE FIFTEENTH EDITION As in past editions, there is a limited increase in the number of medications listed within certain categories and several medications’ regimens have been updated, revised, or deleted from the previous edition. Unless specifically noted, the medication regimens included in this booklet are intended for the adult population. A list of prescription requirements and safe writing practices is included. A chart of weight and equivalents is on the inside front cover; the newly revised indications for American Heart Association’s guidelines of antibiotic prophylaxis for bacterial endocarditis prevention during dental procedures is located on the inside back cover. Every effort has been made to ensure the accuracy of the contents of this booklet; however, the author is not responsible for any typographical errors and the clinician should always verify the accuracy of the information provided. A special thanks to my colleagues Drs. J. Michael Hall and Lynn Solomon for their helpful manuscript suggestions. Michael A. Kahn, D.D.S. Professor and Chairman Department of Oral and Maxillofacial Pathology—Suite DHS-646 Tufts University School of Dental Medicine 1 Kneeland Street Boston, MA 02111 December, 2011

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TABLE OF CONTENTS I. Antibiotics and Antimicrobials ......................................1 II. Antihistamines and Palliative Coating Agents (Magic Mouthwashes) ....................................12 III. Topical Anesthetics, Chemical Cauterizers, and Keratolytic Agents ...............................................14 IV. Antifungals ................................................................17 V. Immunosuppressives, Occlusive Dressings, and Compounds ........................................................24 VI. Antiviral Agents/Viral-Blocking Agents/ Germicidals ...............................................................46 VII. Muscle Relaxants.......................................................51 VIII. Antianxiety Agents (Anxiolytics) for Stress Management...................................................53 IX. Antidepressants .........................................................55 X. Analgesics .................................................................55 XI. Local Anesthetics.......................................................64 XII. Vasoactive Drugs .......................................................66 XIII. Antixerostomics and Fluoride Gels/Rinses ..................67 XIV. Tooth Desensitizers....................................................75 XV. Hemostatic Agents (Topical and IV) ............................76 XVI. Burning Mouth Syndrome, Neuralgia, and Myofascial Pain ...................................................78 XVII. Nutrient Deficient and Supplement Therapy ...............84 XVIII. Taste and Smell Disorder Therapies ...........................85 XIX. Miscellaneous Over-the-Counter Oral Rinses and Products to Relieve Mouth Pain ...........................86 XX. Herbal and Nonherbal Remedies ................................90 XXI. Management of Patients Receiving Radiation or Chemotherapy........................................93 XXII. HIV Infection and AIDS ...............................................97 XXIII. Halitosis ....................................................................99 XXIV. Prescription Requirements and Safe Writing Practices ..............................................100 Compounding Centers of America Phone Contact ................101 Dangerous Prescription Abbreviations .................................101 Relative Potencies of Selected Topical Corticosteroids .........102 References .........................................................................103 Index ..................................................................................109

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I. ANTIBIOTICS AND ANTIMICROBIALS Amoxicillin 50 mg/ml (Amoxil®, Trimox®, Wymox®) [Child] Dsp: 200 ml Sig: Take 1 hour before dental procedure. Use: For penicillinase-resistant infection. Note: 50 mg/kg; total children’s dose should not exceed adult dose. Amoxicillin 500 mg (Amoxil®) Dsp: #40 Sig: Take 1 tablet every 6 hours for 10 days. Use: For penicillinase-resistant infection. Caution: Decrease the dosage by 25–50% in the renal compromised patients. Affects the potency of oral contraceptives. Amoxicillin 500 mg/clavulanate 125 mg (Augmentin®) Dsp: #30 Sig: Take 1 tablet every 8 hours for 10 days. Use: For penicllinase-resistant infection (inhibits betalactamases). Note: Take with food/milk to decrease GI effects. Caution: Decrease the dosage and/or frequency of administration in renal-compromised patients. Azithromycin 250 mg, 500 mg, 600 mg (Zithromax®; Zmax®) Dsp: #6 Sig: Take 2 capsules on day 1 at bedtime, then 1 capsule every day for the next 4 days. Use: For mild to moderate infections of the upper respiratory tract, lower respiratory tract, uncomplicated skin, and skin structure infections caused by M. catarrhalis, S. pneumonia, S. pyogenes, S. aureus, H. influenzae, Clostridium, and L. pneumophila. Alternate drug for penicillin-allergic patients. Note: Extended spectrum of activity. Antacids decrease the absorption. Safe to use during pregnancy and endstage renal disease. Generic formulations are available. Zmax is a single-dose enhancement (extended release) of Z-pak (six 250-mg tablets taken over 5 days). Caution: Decreases action of clindamycin, penicillins, lincomycin, oral contraceptives. Contraindicated in liver disease. May potentiate the effects of oral anticoagulants. 1

Cefaclor 500 mg (Ceclor®) Dsp: #40 Sig: Take 1 capsule every 8 hours. Use: Bactericidal; soft tissue infection of susceptible microorganism. Caution: May cause a false-positive clinitest; renal or hepatic dysfunction; GI disease, especially colitis. Cefaclor 125 mg/5 ml suspension (Ceclor®) [Child] Dsp: 150 ml Sig: For greater than 1 month: 20–40 mg/kg/day divided every 8–12 hours; maximum dose is 2 g/day. Use: Bactericidal; soft tissue infection of susceptible microorganism. Note: Twice-daily option is for treatment of otitis media and pharyngitis. Caution: May cause a false-positive clinitest; renal or hepatic dysfunction; GI disease, especially colitis. Cefditoren pivoxil 200 g (Spectracef®) Dsp: #20 Sig: Take 1 tablet twice daily for 10 days. Use: Bactericidal; mild to moderate pharyngitis/tonsillitis in adults and adolescents caused by S. pyogenes. Note: Not recommended when long antibiotic treatment is necessary. Caution: Contraindicated in patients with carnitine deficiency. Dosage adjustments are necessary for patients with moderate to severe renal insufficiency. The pharmokinetics have not been studied in patients with severe hepatic impairment nor for the prevention of rheumatic fever following S. pyogenes pharyngitis/ tonsillitis. Warning: If given to penicillin-sensitive patients, caution should be exercised because cross-hypersensitivity among beta-lactam antibiotics has been clearly documented. Cephalexin monohydrate 250 or 500 mg (Keflex®) Dsp: #40 Sig: Take 1 capsule every 6 hours for 7 days. Use: Bactericidal; possible drug of choice when penicillin is ineffective in 48 hours for g (+) infections; often ineffective for penicillinase-secreting organisms; seems 2

to have less cross-allergenicity than other cephalosporins (e.g., cephalothin sodium, cephadrine, cefoxitin). Caution: Do not give more than 4 g/day. Decrease the dosage in renal-compromised patients. Cephalexin monohydrate 125 mg/5 ml suspension (Keflex®) [Child] Dsp: 200 ml Sig: 25–50 mg/kg/day every 6 hours; severe infections: 50–100 mg/kg/day in divided doses every 6 hours; maximum: 3 g/24 hours. Use: Bactericidal; possible drug of choice when penicillin is ineffective in 48 hours for g (+) infections; often ineffective for penicillinase-secreting organisms; seems to have less cross-allergenicity than other cephalosporins (e.g., cephalothin sodium, cephadrine, cefoxitin). 0.12% chlorhexidine gluconate (Peridex®; PerioGard®, generics) Dsp: 480 ml Sig: Swish 1 tsp for 1 minute then expectorate; perform twice daily morning and evening after tooth brushing. Avoid eating or drinking for 30 minutes. Use: reduces the pathogenic microbial flora associated with inflammatory signs of oral disease. Caution: May stain teeth yellow to brown; alter taste temporarily; increase the deposition of calculus. Contains 11.6% alcohol. 0.12% chlorhexidine gluconate oral rinse without alcohol (CHX®) Dsp: 480 ml Sig: Swish 15 ml for 1 minute then expectorate; twice daily morning and evening after tooth brushing and meals. Avoid eating or drinking for 30 minutes. Use: Reduces the pathogenic microbial flora associated with inflammatory signs of oral disease. Caution: May stain teeth yellow to brown; alter taste temporarily; increase the deposition of calculus. 0.2% aqueous chlorhexidine gluconate (compounded by pharmacist; only ask for peppermint, raspberry, or spearmint flavoring agents). 3

Dsp: 480 ml Sig: Swish 1 tsp for 1 minute then expectorate; perform twice daily morning and evening after tooth brushing. Avoid eating or drinking for 30 minutes. Use: Reduces the pathogenic microbial flora associated with inflammatory signs of oral disease. Note: For alcoholics and patients with xerostomia (e.g., post-irradiation) because a non-alcohol formulation. Available only through a specialty-compounding pharmacist. To find your nearest pharmacist who participates in the Compounding Centers of America, call 1-800-331-2498. 6-month shelf life. Caution: may stain teeth yellow to brown; alter taste temporarily; increase the deposition of calculus. Ciprofloxacin 250–750 mg (Cipro®) Dsp: #14. Sig: Take 1 tablet 2 times a day for 7 days. Use: Complex periodontal infections (very effective against staph infections). Note: It can be used in combination with metronidazole (i.e., 500 mg of ciprofloxacin twice daily. for 7 days with 250 mg of metronidazole 250 4 times daily for 7 days. Antacids decrease absorption; cimetidine increases levels. Caution: Can cause CNS stimulation. Causes cyclosporine and theophylline toxicity. Do not administer with dairy foods. Contraindicated in patients receiving tizanidine (Zanaflex®). Clarithromycin 250 or 500 mg (Biaxin®) Dsp: #14 Sig: Take 2 tablets per day for 7 days. Use: For mild to moderate infections of the upper respiratory tract and maxillary sinusitis. Active against gram-negative anaerobes in addition to bacteria that erythromycin is effective against. Note: Can be taken with food and dairy products. Caution: Decreases effect of anticholinergic drugs and increases effects of cyclosporine and warfarin. Decreases action of clindamycin, penicillins, lincomycin, oral contraceptives, rifabutin, rifampin, and zidovudine. Contraindicated with terfenadine, astemizole, and 4

cisapride. Avoid in pregnancy and hepatic or renal disease. Clindamycin 150 mg or 300 mg (Cleosin HCl®) Dsp: #60 Sig: Take 1 capsule every 6 hours for 7 days. Use: Bacteriostatic, may be bactericidal; most effective against Bacteroides infections, most other anaerobes, staphylococci; not effective against enterococci. Note: Dosage does not need to be altered in mild or moderate renal or hepatic disease, but 50% reduction is necessary in end-stage renal disease or cirrhosis. Caution: May cause clostridia pseudomembranous ulcerative colitis 2–9 days after the start of therapy; discontinue immediately. Clindamycin 75 mg/5 ml (Cleosin Pediatric®) [Child] Dsp: 100 ml Sig: Take in 3–4 equally divided doses. Use: Bacteriostatic, may be bactericidal; most effective against Bacteroides infections, most other anaerobes, staphylococci; not effective against enterococci. Note: 8–25 mg/kg Caution: May cause clostridia pseudomembranous ulcerative colitis. Dicloxacillin 250 mg (also 500 mg) (Dynapen®, Dycill®) Dsp: #40 Sig: Take 1 tablet every 4 hours for 5–7 days. Use: Bactericidal; possible drug of choice when penicillin is ineffective in 48 hours; effective for staphylococci resistant to penicillin G or penicillinase-secreting organisms; much higher blood level than methicillin (beta-lactamase–resistant penicillin). Note: Should be taken on an empty stomach. Caution: Use with caution in renal-compromised patients (decrease the dose); increases the effectiveness of anticoagulants. Doxycycline 200 mg (Vibramycin®) Dsp: #15 Sig: Take 1 tablet at bedtime on first day, then 100 mg/ day at bedtime for 7–10 days (usually 10 days). 5

Use: Periodontal disease, same as tetracycline HCl. Note: Can be used safely in patients with renal disease without dose alterations. Increases the effect of coumadin and causes digoxin toxicity. Can be given with food. Caution: Avoid in children under the age of 8, in pregnant patients, and those with severe liver disease. Decrease the dose by 50% if the patient has severe liver disease but can be used in mild to moderate liver disease without dose alteration. Do not give in patient with both liver and kidney disease. Doxycycline hyclate 10.0% (Atridox®); in the ATRIGEL® delivery system Dsp: 1 pouch Sig: 1 pouch containing a doxycycline hyclate syringe (50 mg), an ATRIGEL Delivery System syringe (450 mg), and a blunt cannula. The final blended product is 500 mg of formulation containing 50.0 mg of doxycycline hyclate. Use: Chronic adult periodontitis for a gain in clinical attachment, reduction in probing depth, and reduction in bleeding upon probing. Doxycycline hyclate 20 mg (Periostat®) Dsp: #60 Sig: Take 1 capsule twice daily, at least 1 hour prior to meals, as an adjunct following scaling and root planing for up to 9 months. Intake of adequate amount of fluids along with the capsules is recommended. Use: Adjunct to scaling and root planing to promote attachment level gain and to reduce pocket depth in patients with adult periodontitis. Caution: Safety beyond 12 months and efficacy beyond 9 months have not been established. Erythromycin ethylsuccinate 400 mg (EES®, ERYC®, Ery-Tab®) Dsp: #56 Sig: Take 1 tablet 3 times a day. Continue for 7 days. Use: Bactericidal; upper and lower respiratory tract acute infections, soft tissue infections. Note: Inhibits cytochrome P-450 enzyme in the liver, thus decreasing the clearance of theophylline, cyclosporine, and carbamazepine. 6

Caution: Avoid in patients with liver disease. Causes digoxin and theophylline toxicity. Erythromycin ethylsuccinate oral suspension 200 mg/5 ml (E.E.S.®, EryPed®) [Child] Dsp: 200 ml Sig: Prescribe 30–50 mg/kg/day divided every 6–8 hours; do not exceed 2 g/day. Use: Bactericidal; upper and lower respiratory tract acute infections, soft tissue infections. Erythromycin stearate 500 mg (Erythromycin®) or E-mycin 250 mg Dsp: #40 Sig: Take 1 tablet every 6 hours for 10 days. Use: Bacteriostatic; odontogenic infections in patients allergic to penicillin (second choice for oral abscesses), active against gram (+) cocci, may be useful against Haemophilus spp. and Mycoplasma spp.; Legionnaire’s disease; also available IM, IV. Metronidazole 500 mg (Flagyl®) Dsp #30 Sig: Take 2 tablets immediately, then 1 tablet every 6 hours for 7 days. Use: Anaerobic soft tissue infections caused by anaerobic cocci, bacteroides, and clostridium; for febrile patient with acute necrotizing ulcerative gingivitis involving anaerobic bacteria. Note: Useful as a single agent or in combination with amoxicllin, Augmentin®, or ciprofloxacin in the treatment of periodontitis associated with the presence of Actinobacillus actinomycetemcomitans. Caution: Avoid alcohol and do not use in patients with liver or kidney disease. Minocycline 4 mg bioresorbable powder in a disposable cartridge (Arestin®) Dsp: 1 unit-dose cartridge Sig: Insert 1 unit-dose cartridge in supplied handle and then place in each periodontal diseased pocket (variable dose depending on size, shape, and number of pockets being treated). 7

Use: An adjunct to scaling and root planing procedures for the reduction of pocket depth in patients with adult periodontitis. Note: Administered after periodontal scaling and root planing. Specifically, the cartridge is placed at the base of the pocket and then the thumb ring in the handle mechanism is pressed to expel the powder while gradually withdrawing the tip from the base of the pocket. The handle should be sterilized between usages. Caution: Warn patients to avoid eating hard, crunchy, or sticky foods for 1 week and postpone brushing for a 12-hour period, as well as avoid touching treated areas. Patients should also postpone the use of interproximal cleaning devices for 10 days after administration. Not recommended for use in an acutely abscessed periodontal pocket. Warning: The use of drugs of the tetracycline class during tooth development may cause permanent discoloration of the teeth. Photosensitivity manifested by an exaggerated sunburn reaction has been observed in some individuals. Penicillin G 500 mg Dsp: #40 Sig: Take 1 tablet every 6 hours. Use: Bactericidal; active against g (+) cocci aerobic and anaerobic, not beta-lactamase–producing staphylococci; most anaerobes except Bacteroides fragilis are susceptible; also available IV. Penicillin V potassium 250 or 500 mg (Veetids®) Dsp: #28 Sig: Take 1 tablet 4 times a day for 5–7 days. Use: Oral bacterial and viral infections. Note: The most effective antibiotic for the majority of the oral infections. Effective against Strep. viridans, group A strep, anaerobic strep, bacteroides, gram-negative rods, and many, but not all staphylococci. Caution: Avoid in renal compromised patients; no longer recommended for dental procedure prophylaxis. Penicillin V potassium liquid 125 mg/5 ml (Pen-Vee K® liquid) [Child] Dsp: 200 ml Sig: Take 1 tsp every 6 hours. 8

Use: Bactericidal; odontogenic infections (e.g., abscess, cellulitis), ANUG with fever, oral gonorrhea. Same as penicillin G although less active against anaerobes than penicillin G. Phenoxymethyl penicillin V 500 mg Dsp: #40 Sig: Take 2 tablets immediately and then 1 tablet every 6 hours before meals. Use: Bactericidal; odontogenic infections (e.g., abscess, cellulitis), ANUG with fever, oral gonorrhea. Same as penicillin G although less active against anaerobes than penicillin G. Tetracycline HCl 500 mg (Achromycin V®) Dsp: #40 Sig: Take 1 tablet or capsule every 6 hours. Continue for 7 days. Use: Bacteriostatic; active against many anaerobes and enteric gram negative rods. Fair activity against Strep. viridans. Tetracycline HCl oral suspension 250 mg/tsp (Achromycin®) Dsp: 4 oz Sig: Take 1 teaspoon 4 times a day, rinse orally 5 minutes and swallow. Use: Minor, major, and herpetiform aphthous stomatitis; active against certain g (+) cocci; Bacteroides fragilis commonly resistant but not Actinobacillus spp. or Capnocytophaga; also can be dispensed IM or IV. Caution: Use Doxycycline hydrate (Vibramycin) if renal impairment or tooth staining a factor (pregnancy and younger than 8 years old); dairy and antacid products can inactivate. Tetracycline HCl 250 mg (Tetracyn®) Dsp: #40 Sig: Dissolve 1 tablet in 1 tsp of warm water, then swish solution for 3–5 minutes and swallow. Repeat 4 times daily. Use: Reduces the pathogenic microbial flora associated with inflammatory signs of oral disease. 9

Tetracycline HCl 12.7 mg (Actisite®) Dsp: 1 box of 10 fibers Sig: Insert fiber into periodontal pocket up to gingival margin while maintaining contact with pocket base. Secure with cyanoacrylate adhesive. Use: Adjunct to scaling and root planing in patients with active periodontitis. Note: Fibers lost during first 7 days must be replaced. Caution: May reduce the effectiveness of oral contraceptives; may permanently stain teeth; not for use with acute abscesses; remove after 10 days or immediately if erythema occurs. Trimethoprim 80 mg and sulfamethoxazole 400 mg (Bactrim®) Dsp: #40 Sig: Take 1 tablet every 12 hours. Use: For infections involving Escherichia coli, Hemophilus influenzae, Klebsiella, and Enterobacter spp. Note: Usually not used for dental infections. Vancomycin 125 mg (Vancocin®, Lyphocin®) Dsp: #12 Sig: Take 1 tablet 4 times a day for 1 week. Use: Pseudomembranous colitis produced by C. difficile; infections for suspected or documented methicillinresistant Staph. aureus or beta-lactam–resistant coagulase-negative Staphylococcus. Note: Can be given during hemodialysis, at the dialysis site, for SBE prophylaxis. Stays effective for 7 days, postdialysis. Caution: Contraindicated in patients with kidney disease. OVER-THE-COUNTER ANTIMICROBIALS: PerioShield oral heath rinse Dsp: 300 ml Sig: Rinse with 1/2 oz. twice daily for 30 seconds and expectorate. Avoid rinsing or eating for 30 minutes following treatment. Use: Antiplaque and gingivitis agent; relapse prevention tool for post-chlorhexidine treatment and at-home maintenance therapy after scaling and root planing. Note: Proprietary 0.2% delmopinol hydrochloride; not 10

bactericidal but, rather, disrupts the development and maturation of biofilm 10% povidone-iodine solution (Betadine®) Dsp: 8 oz. Sig: Rinse 1 tsp in the mouth for 1 minute and spit out, twice daily. Use: For acute necrotizing ulcerative gingivitis. Note: Should be used for a maximum of only 2 days. Caution: Not to be used in patients allergic to iodine. Solution should be completely spit out. Listerine® liquid Dsp: 1 bottle Sig: Rinse 1 tbsp in mouth for 30 seconds, twice daily. Use: Antiplaque and gingivitis agent. Note: ADA seal of approval. Colgate Total® toothpaste Dsp: 1 tube Sig: Brush teeth with toothpaste 2–3 times a day. Use: Antiplaque and gingivitis agent. Note: ADA seal of approval. OVER-THE-COUNTER REMOVABLE PROSTHESES DISINFECTANTS/CLEANERS 1. Removal of debris and concretions by dishwashing liquid detergent or white vinegar. Ultrasonic cleaners may be used, but there are anecdotal reports of tooth and clasp dislodgment. 2. Soak in full-strength household chlorine bleach (0.525% sodium hypochlorite) for 10 minutes (set timer), then rinse thoroughly in cool water. Repeat weekly. Note: May adversely affect dental alloys, acrylics, and tissue-conditioning material. If the metal does not darken or dull the surface, then it is okay to use. Tufts University School of Dental Medicine: 1. Remove dentures from mouth and clean with a brush at least two times a day. This should be done over a sink filled with water. 2. Once per week, soak denture overnight in a cleansing solution to remove stains and other accumulations. Recommended solution is: 11

Calgon: 2 tsp Clorox: 1 tsp 1 /2 glass of water 3. Rinse well with water before inserting denture back into mouth Warning: Do not place denture with metal into this solution. Use vinegar and water instead OR If metal affected, then try: Soak for 6 hours (or overnight) in Oral Safe (sodium benzoate, citric acid, disodium phosphate, glycerin, water, FD and C blue, and C yellow #5, sodium saccharin, and flavoring) to eliminate recoverable surface fungi (i.e., C. albicans). Note: The solution is good for 1 week. The pH is 3.4 and it is not corrosive, toxic, or carcinogenic; safe if ingested. Manufactured by Great Lakes Orthodontics, Tonawanda, NY; 1-800-828-7627. Cost is $6.50 for starter kit; 6-month refill kit is $21.00 with $4.00 shipping and handling fee. II. ANTIHISTAMINES AND PALLIATIVE COATING AGENTS (MAGIC MOUTHWASHES) Diphenhydramine HCl 50 mg (Benadryl®) or promethazine 12.5 mg (Phenergan®; generic available) [Child] Dsp: #20 Sig: Take 1 tablet 3 times daily for 2–3 days. Use: Mild to moderate allergic stomatitis of the immediate type, erythema multiforme. Note: Diphenhydramine causes xerostomia. Caution: Do not administer more than 50 mg of diphenhydramine per visit. Do not use during acute asthma attacks; avoid in patients with history of hyperthyroidism or angle-closure glaucoma; should not be used along with alcohol, barbiturates, opioids, and MAO-Is or any other centrally acting drug. Diphenhydramine elixir 12.5 mg/5 ml (Benadryl®) or promethazine syrup 6.25 mg/5 ml (Phenergan®) with Kaopectate (attapulgite) or Milk of Magnesia 4 oz. [Child and Adult] Dsp: 8 oz.; compound the ingredients 12

Sig: Rinse with 1 tsp every 2 hours and expectorate. Use: Allergic stomatitis of the immediate type, erythema multiforme; palliation of painful vesiculoulcerative lesions such as primary herpetic gingivostomatitis; sedation and antiemetic effects. Note: Dyclonine HCl 0.5%, 1 oz may be added for greater anesthetic efficacy. Sucralfate (Carafate®) 1 g/10 ml or Maalox (aluminum hydroxide, magnesium hydroxide) may be substituted for Kaopectate or Milk of Magnesia. Palliative rinse; no therapeutic effect. Allergic reactions are extremely rare. Caution: When topical anesthetics are used, patients should be cautioned concerning a reduced gag reflex and the need for caution while eating and drinking to avoid possible airway compromise. Also, the preparation can cause constipation and drowsiness; Maalox® may be substituted for Kaopectate or Milk of Magnesia if constipation is a problem. Benacort-tetrastat elixir (Mary’s magic potion®) Dsp: 1.5 g tetracycline, 60 mg hydrocortisone, 6 million international units nystatin, 240 ml q.s. elixir of Benadryl Sig: Rinse with 1 tsp 4 times daily for 2 minutes and expectorate Use: Severe mucositis; sedation effects. Caution: In xerostomic patients, it increases likelihood of caries. Weisman’s Philadelphia mouthwash Dsp: 80 ml oral 2% viscous lidocaine, 80 ml Maalox (aluminum hydroxide, magnesium hydroxide), 80 mg hydrocortisone, 160 ml distilled water Sig: Rinse with 1 tsp 4 times daily for 2 minutes and expectorate. Use: Severe mucositis. 1-2-3 mouth rinse Dsp: 40 ml Dimetapp elixir, 80 ml Kaopectate (attapulgite), 120 ml distilled water Sig: Shake well and rinse with 1 tsp as needed for 2 minutes and expectorate. Use: Severe mucositis.

13

III. TOPICAL ANESTHETICS, CHEMICAL CAUTERIZERS, AND KERATOLYTIC AGENTS TOPICAL ANESTHETICS 20% benzocaine gel or liquid or spray (Hurricaine®) Dsp: 1 oz. Sig: Apply small amount to ulcer as needed for pain. Use: Palliation of painful vesiculoulcerative lesions. Caution: The FDA announced in 2011 that over-thecounter benzocaine gels and liquids applied to the gingiva (or other areas of the mouth) have caused a rare but potentially fatal adverse effect, methemoglobinemia. Benzocaine products should not be used on children younger than 2 years of age (e.g., teething), except under the advice and supervision of a healthcare professional. 14% benzocaine with 2% butamben 2% tetracaine gel or liquid or ointment (Cetacaine®) Dsp: 56 g (liquid) or 29 g (gel) or 37 g (ointment) Sig: Apply small amount to ulcer as needed for pain. Use: Palliation of painful vesiculoulcerative lesions. Caution: The FDA announced in 2011 that over-thecounter benzocaine gels and liquids applied to the gingiva (or other areas of the mouth) have caused a rare but potentially fatal adverse effect, methemoglobinemia. Benzocaine products should not be used on children younger than 2years of age (e.g., teething), except under the advice and supervision of a healthcare professional. 0.5% or 1% dyclonine HCl (Dyclone®) Dsp: 4 oz bottle Sig: Rinse with 1 tsp for 2 minutes before each meal and expectorate. Use: Palliation of painful vesiculoulcerative lesions. Note: If you cannot find Dyclone®, have the pharmacist compound it and place it in a mechanical spray pump. To find the nearest pharmacist who participates in the Compounding Centers of America, call 1-800-331-2498. 2% lidocaine HCl viscous (Xylocaine®) Dsp: 100 ml Sig: Apply 3 drops with clean fingertip or cotton-tipped applicator to oral sores as needed for pain, then expectorate; alternatively, 2 tsp may be rinsed in the 14

mouth and then expectorate. For infant or toddler, apply 3 drops to pacifier (see Caution). Use: Palliation of painful vesiculoulcerative lesions. Note: This preparation can be used for infants who are unable to rinse. Caution: Do not swallow to avoid anesthetizing gag reflex; parents should be instructed to observe the child closely while he or she is taking food or liquids following administration of the anesthetic. Reports of cutaneous overuse leading to life-threatening events such as arrhythmias and seizures. 5% lidocaine HCl liquid (Xylocaine®) Dsp: 450 ml Sig: Swish with 1 tbsp before each meal and expectorate. Use: Palliation of painful vesiculoulcerative lesions. 5% lidocaine ointment (Xylocaine®) Dsp: 35 g Sig: Apply small amount to ulcer as needed for pain. Use: Palliation of painful vesiculoulcerative lesions. 10% lidocaine spray (Xylocaine®) Dsp: 4 oz Sig: Spray for 2 seconds on ulcer as needed for pain. Use: Palliation of painful vesiculoulcerative lesions. Orabase with benzocaine Dsp: 5 g (or 15 g) Sig: Apply to affected area before meals and as needed for pain. Use: Palliation of painful vesiculoulcerative lesions (e.g., aphthous ulcer). Caution: The FDA announced in 2011 that over-thecounter benzocaine gels and liquids applied to the gingiva (or other areas of the mouth) have caused a rare but potentially fatal adverse effect, methemoglobinemia. Benzocaine products should not be used on children younger than 2 years of age (e.g., teething), except under the advice and supervision of a healthcare professional. CHEMICAL CAUTERIZERS Debacterol® single-use applicator package (30% sulfuric acid and 22% sulfonated phenolics); 1 box (24 15

individually wrapped applicator sets consisting of a prefilled [0.2 ml] cotton swab applicator and drying cotton swab) Dsp: 1 applicator package Sig: Dry the affected area using the drying swab. Hold the applicator with the colored ring pointing up. To start the flow of Debacterol, gently bend the colored ring to one side until it snaps. Debacterol will flow to the opposite end (e.g., applicator swab). Apply directly to affected area for no more than 5 seconds. Rinse thoroughly with water and expectorate. Dispose of used applicator. Use: Immediate palliation of painful minor aphthous ulcer. Note: If excess irritation occurs during use, a rinse with sodium bicarbonate (baking soda) will neutralize the reaction (use 0.5 tsp in 120 ml of water). Polyphenolsufonic acid complex, 100 ml, formaldehyde solution, 18 ml, distilled water, 42 ml [Negatan®] Dsp: Compound the ingredients Sig: Dry ulcer and then apply 1 drop for 15 seconds and then rinse with water. Use: Palliation of painful vesiculoulcerative lesions (e.g., aphthous ulcer). Note: Negatan® is no longer available in the United States. Have the pharmacist compound it. Call 1-800-331-2498 to find the nearest pharmacist who participates in the Compounding Centers of America. Silver nitrate Dsp: 1 oz. Sig: Dry ulcer thoroughly, then apply topical anesthetic; lightly apply the silver nitrate on an applicator to the ulcer base for 5 seconds, then rinse with water. Use: Palliation of painful minor aphthous ulcer. Caution: The clinician must use extreme care not to burn adjacent uninvolved mucosa by drying the area thoroughly before applying the cauterizing agent. KERATOLYTIC AGENT 10% podophyllum resin (Podofin®) and benzoin tincture compound solution Dsp: 10 ml Sig: Dry the mucosal surface and apply 1 drop at a time allowing drying between drops. Apply until area is 16

covered but do not apply more than a volume of 0.5 ml at each treatment session. Use: Viral conditions such as condyloma acuminatum. Off-label use for excess keratinization of mucosal surfaces such as hairy tongue. Caution: A 25% solution may be used on skin but limit to 10% solution on or near mucosal surfaces. IV. ANTIFUNGALS Amphotericin B oral suspension 100 mg/ml Dsp: 48 ml Sig: Swish 1 ml 4 times a day in the mouth (after meals and at bedtime) for 3–4 minutes and swallow. Do not eat or drink for 30 minutes after use. Use: Mucocutaneous and oropharyngeal candidiasis when topical therapy is ineffective. Note: Fungizone® product is no longer available. Amphotericin B oral suspension 100 mg/ml Dsp: 24 ml Sig: Swab 1 ml 4 times a day in the mouth (after meals and at bedtime) for 3-4 minutes and swallow. Do not eat or drink for 30 minutes after use. Use: Mucocutaneous and oropharyngeal candidiasis when topical therapy is ineffective and the patient is debilitated and cannot rinse. Note: Fungizone trade name product is no longer available. Can dilute to 100 mg/4 ml for easy swish and expectorate. Amphotericin B 3% cream Dsp: 20 g tube Sig: Apply to affected areas 2–4 times/day for 1–4 weeks of therapy depending on the nature and severity of the infection. Use: Mucocutaneous and cutaneous Candida infections. Anidulafungin 50 mg (Eraxis®) Dsp: Injection, powder for reconstitution Sig: IV adults, for candidemia, intra-abdominal, or peritoneal: 200-mg loading dose on day 1, followed by 100 mg daily for at least 14 days after last positive culture; for esophageal, 100-mg loading dose on day 1, 17

followed by 50 mg daily for at least 7 days after symptom resolution. Use: Esophageal candidiasis, candidemia, abdominal abscesses and peritonitis with Candida (echinocandin) Caspofungin acetate 50 mg and 70 mg (Cancidas®) Dsp: Injection, powder for reconstitution, as acetate Sig: IV infusion slowly, over 1 hour: esophageal, 50 mg/ day; invasive aspergillus, initial dose of 70 mg on day 1, subsequently 50 mg/day. Use: Invasive aspergillus infections in patients who are refractory or intolerant of other therapy; candidemia and other Candida infections (intra-abdominal abscesses, esophageal, peritonitis, pleural space). Warning: Concurrent use of cyclosporine should be limited to patients for whom benefit outweighs risk owing to a high frequency of hepatic transaminase elevations Clotrimazole troches 10 mg (Mycelex®) Dsp: #70 Sig: Dissolve, in mouth, 1 troche as a lozenge 5 times daily for 14 consecutive days. Use: Fungicidal; oral candidiasis. Note: Remove denture(s) if applicable. Do not eat or drink for 30 minutes following use. Troche contains sucrose, risk of caries with prolonged use (>3 months); care must be exercised in diabetic patients. Clotrimazole 1% cream (Lotrimin-Rx®, generic) Dsp: 15 g Sig: Apply thin film to inner surface of denture and/or angles of mouth 4r times a day (after each meal and at bedtime). Use: Denture sore mouth; angular cheilitis. Note: Do not eat or drink for 30 minutes following use. Continue for at least 3 days after apparent clinical resolution. An inexpensive over-the-counter athlete’s foot cream (Lotrimin AF) is also available and may be substituted and used identically. Clotrimazole 1% and betamethasone cream (Lotrisone®) Dsp: 15 g tube Sig: Apply a thin amount to the affected area twice daily. Use: Angular cheilitis. 18

Clotrimazole 10 mg/ml suspension [Infant or Child] Dsp: 90 ml; the pharmacist should blend 900 mg of clotrimazole powder into to 2 tubes of Oral Balance moisturizing oral gel. Sig: Swab 1–2 ml on affected area 4 times a day (after meals and at bedtime). Use: Fungicidal; oral candidiasis in debilitated patients who cannot rinse and for very young children when a rinse is ineffective. Note: Shake before using; do not eat or drink for 30 minutes following use. To find your nearest pharmacist who participates in the Compounding Centers of America, call 1-800-331-2498. Fluconazole 100 mg tablets (Diflucan®); also available in 50 mg, 150 mg and 200 mg tablets Dsp: #15 Sig: Take 2 tablets on first day, then take 1 tablet daily thereafter for 14 days to treat oral candidiasis; for 21 days to treat esophageal candidiasis. Take 4 tablets on first day, then take 2 tablets for 28 days to treat systemic candidiasis. Use: Systemic fungal infection—oropharyngeal, esophageal, mucocutaneous and systemic candidiasis (HIV-seropositive patients). Caution: Avoid in patients with severe liver and kidney disease. Fluconazole 100 mg tablets (Diflucan®)/hydrocortisone 10 mg and iodoquinol 10 mg (Alcortin A gel®) Dsp: 11 tablets/30 g tube Sig: Apply a thin film of cream to the affected area 3–4 times daily for 10 days in conjunction with 200 mg of fluconazole immediately on day 1 and 100 mg each day on days 2–10. Use: Severe exfoliative cheilitis (chapped lips). Note: Patient must stop lip licking habit for complete resolution. Flucytosine 250 mg or 500 mg (Ancobon®) Dsp: #30 Sig: Take 50–150 mg/kg/day in divided doses every 6 hours. Use: Adjunctive treatment of susceptible fungal infection; used in combination with amphotericin B, fluconazole, or 19

itraconazole. Synergistic with amphotericin B for fungal infections (Aspergillus spp.). Hydrocortisone 10 mg and iodoquinol 10 mg (Alcortin A gel®) Dsp: 30 g tube Sig: Apply small dab to corner of mouth, 4 times a day. Use: Angular cheilitis; candidiasis. Note: Advise patient to avoid contact with oral cavity because it has a very bitter taste. Hydrocortisone 2% and iodoquinol 1% (Alcortin A gel®) Dsp: 24-pack box (48 g) Sig: Apply as a thin film 3–4 times daily to the affected area. Use: Angular cheilitis; candidiasis. Note: Do not use with an occlusive dressing. Itraconazole 100 mg (Sporanox®) Dsp: #28 Sig: Take 1 capsule twice daily or 2 tablets with a meal or orange juice. Use: Fungistatic; oral candidiasis when topical therapy is not practical or is ineffective. Also may be used for blastomycosis and histoplasmosis, Aspergillus, Coccdioides, Cryptococcus, Sporothrix, and chromomycosis. Note: Dose may be increased 100 mg/day to 400 mg/day. Doses greater than 200 mg/day should be given in 2 divided doses. Caution: May cause irreversible liver damage; avoid in congestive heart failure. Itraconazole 10 mg/ml oral solution (Sporonox®) Dsp: 150 ml Sig: Swish in mouth and swallow 200 mg daily for 1–2 weeks. Use: Fungistatic; oral candidiasis when other topical therapy is ineffective. Also may be used for blastomycosis and histoplasmosis, Aspergillus, Coccdioides, Cryptococcus, Sporothrix and chromomycosis. Note: Dose may be increased 100 mg/day to 400 mg/day. 20

Doses greater than 200 mg/day should be given in 2 divided doses. Caution: May cause irreversible liver damage. Ketoconazole cream 2% (Nizoral®, generic) Dsp: 15 g, 30 g, or 60 g tube Sig: Rub gently to affected area 1–2 times per day. Use: Fungistatic; oral candidiasis, angular cheilitis. Note: If denture wearer, apply thin film to inner surface of denture. Do not eat or drink for 30 minutes following use. Caution: May cause irreversible liver damage. Ketoconazole cream 2% (Nizoral®, generic) mixed with equal parts of triamcinolone acetonide 0.1% or 0.5% ointment (Kenalog) or fluocinonide 0.05% ointment (Lidex®) or clobetasol 0.05% ointment (Temovate®). Dsp: 30 g Sig: Apply thin film to inner surface of dentures or medication trays twice daily. May also gently rub into the affected area once or twice daily. Use: Candidiasis. Ketoconazole 200 mg (Nizoral®, generic) Dsp: #14 Sig: Take 1 tablet daily, with a meal, for 2 weeks. Use: Fungistatic; oral and mucocutaneous candidiasis when patient cannot tolerate topical therapy or respond to topical (e.g., nystatin). Note: Do not take antacids within 1 hour of this medication. Caution: May cause irreversible liver damage; liver function should be monitored with long-term use (>3 weeks). Multiple severe drug interactions possible, especially with some antihistamines. Micafungin sodium 50 mg (Mycamine®) Dsp: IV adults: powder for reconstitution as sodium; contains lactose. Sig: For esophageal candidiasis, 150 mg daily with median trial of 14 days; for prophylaxis of Candida infection in hematopoietic stem cell transplantation 50 mg daily with median trial of 18 days. Use: Inhibits cell wall synthesis (new echinocandins class); esophageal candidiasis; prophylaxis in patients 21

undergoing hematopoietic stem cell transplant. Unlabeled use for aspergillus infections and prophylaxis for HIVrelated esophageal candidiasis. Note: Side effects include isolated serious cases of serious hypersensitivity and anemia as well as changes in liver and kidney function. Miconazole buccal 50 mg tablets (Oravig®) Dsp: 14 tablets Sig: Apply 1 mucosa-adhering tablet to the gingiva daily for 2 weeks. Use: Oropharyngeal candidiasis (especially immunedepressed patients); also may be preferred in patients suffering from salivary gland hypofunction compared with other azoles. Note: Cost can be prohibitive for some patients; however, single dose per day enhances patient compliance. Caution: Monitor in patients with a history of hypersensitivity to azoles. Nystatin oral suspension 100,000 IU/ml (Mycostatin®, Nilstat®) Dsp: 240 ml Sig: Take 1 tsp (2–5 ml) every 6 hours (after each meal and before bedtime), rinse orally for 2 minutes then swallow (if pharyngeal involvement) or expectorate, for 1 week. Do not eat or drink for 30 minutes following application. Use: Oral candidiasis. Note: Remove denture(s) if applicable; a few drops can be added to the water used for soaking acrylic prostheses. If dentate, good oral hygiene should be reinforced because nystatin suspension has a high sugar content (50%). Advise the patient to regularly brush his or her palate if he or she has a removable maxillary prosthesis. Nystatin pastilles or troches 200,000 IU (Mycostatin®) Dsp: #80 Sig: Dissolve 1 pastille in mouth 4 times daily as a lozenge for 14 consecutive days. Use: Oral candidiasis. Note: Remove denture(s) if applicable. If dentate, good oral hygiene should be reinforced because nystatin suspension has high sugar content. Advise the patient 22

to regularly brush her or his palate if she or he has a removable maxillary prosthesis. Do not chew the pastille. More effective than the oral suspension. Nystatin topical powder 100,000 IU (Mycostatin® topical powder) Dsp: 15 g squeeze bottle Sig: Apply liberally to tissue side of clean denture after meals and after rinsing the denture. Soak the denture in a suspension of 1 tsp of powder and 8 oz. of water overnight. Use: Denture-related candidiasis. Note: If dentate, good oral hygiene should be reinforced because nystatin suspension has high sugar content. Advise the patient to regularly brush his or her palate if they he or she has a removable maxillary prosthesis. Nystatin ointment 100,000 IU (Mycostatin®, Nilstat®, generic) Dsp: 15 g (or 30 g) tube Sig: Apply thin film to affected area and to inner surface of denture, after each meal and at bedtime, until healing occurs. Do not eat or drink for 30 minutes after use. Use: Denture-related candidiasis; angular cheilitis. Note: Inexpensive; a polyethylene and mineral oil gel base. Can be mixed with a topical steroid ointment (see p. 37). Also available as an aqueous vanishing cream base. Nystatin 100,000 units/g—triamcinolone acetonide 0.1% ointment (Mycolog II®, Mytrex®) Dsp: 15 g (30 g, 60 g) tube Sig: Apply to the corner of the mouth after each meal and at bedtime until healing occurs. Use: Angular cheilitis. Note: Concomitant intraoral antifungal treatment may be indicated. As with nystatin ointment, in denture wearers, this may be applied as a thin film to the inner surface of the denture. Nystatin 100,000 units/g—triamcinolone acetonide 0.1% ointment (Mycolog II®, Mytrex®) and erythromycin gel 2% Dsp: Compound 30 mg of Mycolog II and 30 mg of erythromycin gel in a 1:1 ratio 23

Sig: Apply to corner of the mouth after each meal and 1 /2 hour before bedtime until healing occurs. Use: Especially useful for recalcitrant angular cheilitis that has been secondarily infected with Staph. aureus. Caution: Ensure patient is not allergic to erythromycin. OVER-THE-COUNTER PREPARATIONS 1% clotrimazole vaginal cream (Gyne-Lotrimin®) Dsp: 1 tube (15 g, 30 g, 60 g, or 90 g) Sig: Apply small dab to corner of mouth, 4 times a day OR apply small dab to tissue side of denture or to infected oral mucosa 4 times a day. Use: Angular cheilitis; candidiasis. Clotrimazole 200 mg (Gyne-Lotrimin®) Dsp: 1 box Sig: Dissolve 1/2 vaginal tablet, in mouth, as a lozenge twice daily for 14 consecutive days. Use: Fungicidal; oral candidiasis. Note: Remove denture(s), if applicable. Do not eat or drink for 30 minutes following use. Inexpensive substitute for Clotrimazole prescription cream if the patient is not reluctant to use; however, for some patients, a very bitter taste will be detected. Bitter taste can be counteracted by a sip of milk. 2% miconazole nitrate vaginal cream (Monistat 7®) Dsp: 45 g tube Sig: Apply to affected area and tissue side of denture 4 times a day. Use: Oral candidiasis (denture sore mouth); angular cheilitis. V. IMMUNOSUPPRESSIVES, OCCLUSIVE DRESSINGS, AND COMPOUNDS (FOR CHRONIC VESICULAR/BULLA AND EROSIVE/ULCERATIVE DISEASES) PRESCRIPTION OCCLUSIVE DRESSINGS 0.5% hydrocortisone acetate ointment (Orabase HCA®) Dsp: 5 g tube Sig: Dry area and then apply thin film to oral sores after meals and at bedtime. Do not rub in. Use: Oral erosive lichen planus, bullous pemphigoid, oral pemphigus, contact (delayed) allergic stomatitis, recurrent aphthous stomatitis, chapped (cracked) lips. 24

Delmopinol HCl mouth rinse 2 mg/ml (Decapinol®) Dsp: 1 bottle Sig: Use twice daily after brushing and flossing. Use: Reduce gingivitis Note: Classified by the FDA as a bioadhesive device rather than a drug. A physical barrier is created to prevent aggregation and colonization of bacteria at the tooth and gum interface. It is not antimicrobial or antiseptic. OVER-THE-COUNTER OCCLUSIVE DRESSINGS Alvogyl® (eugenol, butamben, iodoform) Dsp: 11 g jar Use: Dry socket (alveolar osteitis) Avamin Melts® (500 μg methylcobalamin) Dsp: 1 box (60 discs) Sig: Apply 2 dry mucoadhesive discs over the aphthous ulcer on the first day; and then 1 disc each succeeding day. Use: Recurrent aphthous stomatitis Benzoin tincture saturated swabsticks (Aplicare, Inc., Meriden, CT) Dsp: 1 case—10 boxes of 50 single sterile swabstick pouches Use: Topical skin adhesive that prepares the skin for maximum adhesion of dressing or bandages. Note: Can be removed with acetone alcohol or alcohol; order number is S-1106. BetaCell oral rinse (micellized retinyl palmitate, micellized D-alpha-tocopheral, micellized beta carotene, glycerin) Dsp: 16 oz. bottle Sig: Swish 10 ml in the mouth for 60 seconds in the morning and in the evening and expectorate. Note: No alcohol or sugar; natural spearmint flavor; unpublished findings purport reversal of hyperkeratosis and dysplasia. Use: Gingival irritations, denture sores, aphthous ulcers, burns, orthodontic appliance sores, and oral leukoplakia (see note). 25

Canker Cover® mint flavor (oral canker sore patch) (menthol, beta-carotene, citrus oil, magnesium chloride, carbomer) Dsp: 1 box (6 patches) Sig: Apply 1 mucoadhesive patch, white side up, with clean, dry finger for 20 seconds. Use: Recurrent minor aphthous stomatitis. Note: Do not remove patch before it dissolves. If needed, apply a second patch 24 hours after the first application. Cankermelts®—GX (1.4 mg glycyrrhizin [licorice root extract]) Dsp: 1 box (12 patches) Sig: Apply 1 dry mucoadhesive disc for 1–2 minutes over the aphthous ulcer as soon as detected for at least 16 hours per day until 8 hours after you last feel the sore; reapply when patch totally dissolves after 4–6 hours. Use: Recurrent aphthous stomatitis; orthodontic-induced ulcers. Note: To last longer, 2 discs may be used at once, 1 on top of the other. Contains no products of nuts, corn, wheat, rice, grain, soy, egg, fish, shellfish, milk, or yeast. Caution: Do not use more than 90 discs in a 3-day period (30/day) or more than 18 discs every day for 5 days or more. Keep out of reach of children younger than age 6 owing to risk of choking. Gelclair® bioadherent oral gel (no alcohol; key ingredients: polyvinyl pyrrolodone, hyaluronic acid, glycyrrhetinic acid) Dsp: 15 ml per single-dose packet; 1 box contains 21 single-dose packets Sig: 3 times a day or as often as needed, pour entire contents of single-dose packet into glass and add 1 tbsp of water (undiluted or more dilution may be performed to achieve desired viscosity). Stir mixture and immediately rinse for at least 1 minute and expectorate. Avoid eating or drinking for at least 1 hour after use. Use: For recurrent aphthous ulcers and nonspecific small ulcers. Note: Contraindicated in any patient with a known history of hyerpesensitivity to any ingredients. Gel may become a little darker and thicker over time, but this does not affect efficacy or safety. Caution: Keep out of direct sunlight; do not refrigerate. 26

Orabase® Sooth-N-Seal (formulated 2-octyl cyanoacrylate) Dsp: 1 ml (10 uses with 10 applicators) Sig: Apply 2 drops of liquid into a plastic well. Dip pointed end of provided sponge swab into the well; dry affected area with rounded sponge swab end and then dab pointed end of swab on mouth sore for no more than a second. Dab a second time if needed. Do not release lip or cheek for at least 5 seconds. Use: For recurrent aphthous ulcers and nonspecific small ulcers. Note: Do not refrigerate. Caution: Product is a fast-setting adhesive; take care to avoid bonding of product to unintended areas. Avoid all contact with eyes. Not for ingestion (call poison control if accidental ingestion). Orajel® Protective MouthSore Discs (benzocaine 15 mg, carbomer, pregelatinized zea mays [corn] starch) Dsp: 1 box (8 discs) Sig: Apply 1 mucoadhesive disc to sore. Use: Recurrent minor aphthous stomatitis. Caution: The FDA announced in 2011 that over-thecounter benzocaine gels and liquids applied to the gingiva (or other areas of the mouth) have caused a rare but potentially fatal adverse effect, methemoglobinemia. Benzocaine products should not be used on children younger than 2 years of age (e.g., teething), except under the advice and supervision of a healthcare professional. OraMoist® mucoadhesive patch Dsp: 1 box Sig: Apply to affected oral mucosa. Use: Recurrent aphthous stomatitis. Note: If the patch does not attach owing to extremely dry mucosa, then first moisten with water. A nondrug formula composed of time-released lipids, citrus oil, sea salt, enzymes, and xylitol. OraPatch® (acemannan hydrogel—a freeze-dried gel of aloe vera; also known as Carrington patch or Manapol patch) Dsp: 1 box (12 patches) 27

Sig: Clean and dry hands and carefully apply 1 patch to the affected oral mucosa; avoid squeezing patch. Hold against mucosa until adherence and keep the area as dry as possible. Use for pain as needed. Use: Originally developed for aphthous ulcers, but has FDA approval for any type of oral traumatic ulcer; most recently approved for dry socket management. Rincinol P.R.N.® (aloe vera; alcohol-free, no benzocaine or hydrogen peroxide) Dsp: One 4 oz. bottle or 3 on-the-go soft packs per package Sig: After drying area, pour contents of packet into mouth and rinse for 1 minute and expectorate. Use: Nonspecific oral ulcers, aphthous ulcers, minor oral irritations and burns, denture irritation. Zilactin-L® gel (80.8% SD benzyl alcohol 37, 7% tannic acid, 2.5% salicylic acid) Dsp: 5.2 oz. tube Sig: After drying area, apply a thin coat with clean fingertip or cotton-tip applicator over affected tissue every 1–2 hours. Use: Recurrent aphthous ulcers, abrasions, and herpes simplex lesions. ANTI-INFLAMMATORIES STEROIDS Caution: Systemic steroids are contraindicated or must be used with caution in a number of systemic conditions (e.g., steroids raise blood sugar in diabetics). Consultation with a patient’s physician is recommended before prescribing. Most oral pathologists feel that tapering of prednisone is not necessary with 5- to 7-day burst therapy nor is tapering necessary with alternate-day therapy if the dosage does not exceed 20 mg. Steroids are contraindicated if an active infection exists (the microbial proliferation is usually enhanced and systemic dissemination is possible). Baseline hematology laboratory studies to include platelets are necessary to monitor possible bone marrow suppression. Hepatotoxicity has been reported. Special Advice: In order to reduce the possibility of adrenocortical suppression, it is important that 28

prednisone be taken in harmony with diurnal adrenocortical steroid levels. In order to accomplish this, prednisone should be taken 90 minutes after normal arising time. Alternate-day AM dosage also reduces the possibility of adrenocortical suppression. Note: When gingival lesions are prominent, a soft acrylic splint that extends over the attached gingiva can be useful to help occlude the topical steroid gel to the mucosal tissues. On page 102, the relative potencies of selected topical corticosteroids are listed. Compounded Solutions Betamethasone sodium phosphate Lidocaine Diphenadryl cherry Methycellulose 1% solution Ethyl alcohol 190 Stevia Tangerine oil

4.6 g 4.23 g 45 ml 148 ml 1 ml 1.0 g 6 ml

Sig: Rinse, swish, and expectorate solution 4-5 times daily. Note: Flavoring agents are optional. Rather expensive. (Courtesy of Dr. J. M. Hall) Miles’ Mixture 84,000 IU nystatin, 84 mg tetracycline, 1.04 mg hydrocortisone/5 ml liquid Use: Alternate rinse with 2% viscous lidocaine for 2 minutes and expectorate 4 times daily. Use: Major aphthous ulcer in the immunosuppressed [Source: Glick M, Muzyka BC. JADA 1992;123:61–65.] Beclomethasone dipropionate aerosol spray, 40 μg (Qvar® 40, Beclovent®) Dsp: 1 inhaler 7.3 g (40 μg/inh) Sig: Take graduated doses according to the manufacturer’s instruction. Apply spray to back of the oral cavity. Use: Hard-to-reach oral cavity areas such as the tonsillar pillars. Note: Improper use can cause a number of oropharyngeal adverse events including candidiasis and dysphonia. 29

Betamethasone 0.6 mg/5 ml syrup (Celestone®) Dsp: 118 ml Sig: Take 1 tsp 4 times a day. Gargle for as long as possible and expectorate. Use: Oral erosive lichen planus, bullous pemphigoid, oral pemphigus, contact (delayed) allergic stomatitis, recurrent aphthous stomatitis. Note: Taking with food may minimize gastrointestinal distress. Caution: Not recommended for supplementary use in corticosteroid-treated patients undergoing stress; also increased susceptibility to infection. 0.05% betamethasone dipropionate ointment (Diprolene®) Dsp: 15 g (45 g) tube Sig: Apply to oral sores 4 times daily (after meals and at bedtime). Use: Oral erosive lichen planus, bullous pemphigoid, oral pemphigus, contact (delayed) allergic stomatitis, recurrent aphthous stomatitis. Note: Taking with food may minimize gastrointestinal distress. Caution: Warning label states only for external use; tell patient to ignore the label (i.e., off-label use). If candidiasis occurs, then add 100,000 units of nystatin into each gram of the ointment. 0.1% betamethasone valerate ointment (Valisone®) Dsp: 15 g (45 g, 110 g, 430 g) tube Sig: Apply thin amount to oral sores 4 times daily (after meals and at bedtime). Use: Oral erosive lichen planus, bullous pemphigoid, oral pemphigus, contact (delayed) allergic stomatitis, recurrent aphthous stomatitis, chapped (cracked) lips. Note: Taking with food may minimize gastrointestinal distress. Caution: Prolonged use can result in tissue thinning. 0.05% clobetasol propionate gel or ointment (Temovate® or generic) Dsp: 30 g tube 30

Sig: Dry area and apply to oral lesions 4–6 times daily (after meals and at bedtime). Do not rub in. Use: Oral erosive lichen planus, bullous pemphigoid, oral pemphigus, contact (delayed) allergic stomatitis, recurrent aphthous stomatitis, chapped (cracked) lips. Note: The gel formulation has a slightly lower potency than the ointment. If a denture wearer, apply a thin film to the inner surface of the denture base wherever it contacts the oral lesions. 0.05% clobetasol propionate ointment (Temovate or generic) with Orabase or Orabase with benzocaine Dsp: 30 g tube (15 g each, compounded 1:1) Sig: Dry area and apply to oral lesions 4–6 times daily (after meals and at bedtime). Do not rub in. Do not eat or drink anything for 1/2 hour after use. Use: Oral erosive lichen planus, bullous pemphigoid, oral pemphigus, contact (delayed) allergic stomatitis, recurrent aphthous stomatitis, chapped (cracked) lips. Note: Mixing with equal parts of Orabase promotes adhesion and may improve efficacy. Caution: The FDA announced in 2011 that over-thecounter benzocaine gels and liquids applied to the gingiva (or other areas of the mouth) have caused a rare but potentially fatal adverse effect, methemoglobinemia. Benzocaine products should not be used on children younger than 2 years of age (e.g., teething), except under the advice and supervision of a healthcare professional. 0.05% clobetasol propionate and nystatin 100,000 IU/ml aqueous solution Dsp: 100 ml Sig: Swish 10 ml of the solution 3 times daily for 5 minutes. Use: Oral erosive lichen planus. Dexamethasone elixir 0.5 mg/5 ml (Decadron®) Dsp: 100 ml Sig: Take 1–2 tsp as an oral rinse for 2 minutes 3 times a day, then expectorate. Discontinue when lesions become asymptomatic. Use: Minor aphthous ulcerations, other oral erosive stomatitides. 31

Dexamethasone elixir 0.5 mg/5 ml (Decadron®) Dsp: 237 ml Sig: For 3 days, rinse with 1 tbsp 4 times a day and swallow; then for 3 days, rinse with 1 tsp 4 times a day and swallow; then for 3 days, rinse with 1 tsp 4 times a day and swallow every other time; then rinse with 1 tsp four times a day and expectorate. Use: Severe oral erosive lichen planus, severe recurrent aphthous stomatitis, severe benign mucous membrane pemphigoid, erythema multiforme. Note: Discontinue when mouth becomes comfortable; rinse after meals and 1/2 hour before bedtime; if discomfort recurs begin regimen at step 3. Note: Roxane Laboratories offers a sugar-free, dye-free, trace of alcohol oral solution (240 ml; 500 ml) Dexamethasone sodium phosphate injectable 4 mg/ml with lidocaine HCl Sig: Following local anesthesia, inject 0.5–1.0 ml (0.1–0.2 mg per injection site) around margins of ulcer with a 25-gauge needle twice a week until ulcer heals. Use: Very severe cases of oral erosive lichen planus, major aphthous stomatitis, benign mucous membrane pemphigoid, and erythema multiforme. 0.05% fluocinolone gel (Synalar®) [Child or Adult] Dsp: 15 g (30 g, 60 g) tube Sig: Dry area and apply thin amount to oral lesions 4–6 times daily (after meals and at bedtime). Do not rub in. Use: Oral erosive lichen planus, bullous pemphigoid, oral pemphigus, contact (delayed) allergic stomatitis, recurrent aphthous stomatitis, chapped (cracked) lips. Note: A synthetic corticosteroid that differs structurally from triamcinolone acetonide. May be compounded with benadryl. 0.05% fluocinonide gel or ointment (Lidex® or generic) [Child or Adult] Dsp: 15 g (30 g, 60 g) tube Sig: Dry area and apply thin amount to oral lesions 4–6 times daily (after meals and at bedtime). Do not rub in. Use: Oral erosive lichen planus, bullous pemphigoid, oral pemphigus, contact (delayed) allergic stomatitis, recurrent aphthous stomatitis, chapped (cracked) lips. 32

Note: The gel formulation has a slightly lower potency than the ointment but generally has better patient acceptance. If a denture wearer, apply a thin film to the inner surface of the denture base wherever it contact the oral lesions. Caution: Has a bitter taste; patient may prefer betamethasone valerate. 0.05% fuocinonide (Lidex® or generic) ointment compounded 1:1 with Orabase or Orabase with benzocaine Dsp: 30 g total (15 g each) Sig: Dry area and apply to oral lesions 4–6 times daily (after meals and at bedtime). Do not rub in. Use: Oral erosive lichen planus, bullous pemphigoid, oral pemphigus, contact (delayed) allergic stomatitis, recurrent aphthous stomatitis, chapped (cracked) lips. Note: Mixing with equal parts of Orabase promotes adhesion and may improve efficacy. Caution: The FDA announced in 2011 that over-thecounter benzocaine gels and liquids applied to the gingiva (or other areas of the mouth) have caused a rare but potentially fatal adverse effect, methemoglobinemia. Benzocaine products should not be used on children younger than 2 years of age (e.g., teething), except under the advice and supervision of a healthcare professional. 0.05% halobetasol propionate gel (Ultravate®) Dsp: 30 g tube Sig: Dry area and apply to oral lesions 4–6 times daily (after meals and at bedtime). Do not rub in. Use: Oral erosive lichen planus, bullous pemphigoid, oral pemphigus, contact (delayed) allergic stomatitis, recurrent aphthous stomatitis, chapped (cracked) lips. 1% hydrocortisone with polymyxin B, bacitracin, neomycin cream compounded 1:1 with 5% lidocaine ointment Dsp: 5 g tube Sig: Apply to lip sores 3 times a day. Use: Recurrent herpes labialis. Caution: Do not apply during early active (intact vesicle) stages. 33

Methylprednisolone 4 mg (Medrol® Dosepak 21s) Dsp: 1 Dosepak [contains twenty-one 4 mg tablets] Sig: Take graduated daily doses according to the manufacturer’s directions listed on the Dosepak (according to many oral pathologists, the manufacturer’s graduated daily doses [tapering] of this product is not necessary owing to its low dosage). Use: Very severe cases of oral erosive lichen planus, major aphthous stomatitis, benign mucous membrane pemphigoid, and erythema multiforme. Caution: Do not prescribe if patient has existing infectious disease or diabetes mellitus (hyperglycemia danger). 1% pimecrolimus cream (Elidel®) (60 g and 100 g are also available) Dsp: One 30 g tube Sig: Apply twice daily for 2 weeks. Use: Oral erosive lichen planus. Note: Off-label use for oral involvement. Caution: FDA advisory in January 2006 advises may increase the risk of developing cancer and should be used only as a second-line therapy (i.e., a black box warning) Prednisone 10 mg (5 mg and 20 mg are also available) or dexamethasone 0.75 mg Dsp: #40 Sig: Take 1 tablet every 6x hours for 7 days, followed by 1 tablet every 12 hours for 4 days, followed by 1/2 tablet every 12 hours for 3 days. Use: Very severe cases of oral erosive lichen planus, major aphthous stomatitis, benign mucous membrane pemphigoid, and erythema multiforme; varicella zoster (shingles). Note: A high-dose, short course can also be prescribed; 40–80 mg daily for 2 weeks or less (i.e., burst therapy); no tapering needed. When daily dose is 30 mg or greater, patients may experience insomnia, headache, or irritability. Caution: Do not prescribe if patient has existing infectious disease or diabetes mellitus (hyperglycemia danger). Prednisone 10 mg tablets (5 mg and 20 mg are also available) (Deltasone®) 34

Dsp: #50 Sig: Take 5 tablets in the morning (90 minutes after normal arising time) until lesions recede, then decrease by 1 tablet on each successive day OR switch to everyother-day therapy for 4 doses, then stop systemic therapy. The patient may then continue with topical steroid therapy. Use: very severe cases of oral erosive lichen planus, major aphthous stomatitis, benign mucous membrane pemphigoid, and erythema multiforme. Note: When daily dose is 30 mg or greater, patients may experience insomnia, headache, or irritability. Concomitantly administer azathioprine. Caution: Do not prescribe if patient has existing infectious disease or diabetes mellitus (hyperglycemia danger). Prednisone 20 mg tablets (5 mg and 10 mg are also available) (Deltasone®) Dsp: #20 Sig: Take 2 tablets each day for 10 days. Use: Very severe cases of oral erosive lichen planus, major aphthous stomatitis, benign mucous membrane pemphigoid, and erythema multiforme. Note: When daily dose is 30 mg or greater, patients may experience insomnia, headache, or irritability. Caution: Do not prescribe if patient has existing infectious disease or diabetes mellitus (hyperglycemia danger). Prednisone 20 mg tablets (Deltasone) and 0.12% chlorhexidine gluconate mouthwash Dsp: #10 Sig: Take 1 tablet each day for 10 days and rinse with chlorhexidine twice daily. Use: Herpetiform aphthous stomatitis. Caution: Do not prescribe if patient has existing infectious disease or diabetes mellitus (hyperglycemia danger). Prednisolone syrup 15 mg/5 ml (Prelone®) Dsp: 8 oz Sig: Take 1 tsp 4 times a day. Gargle or swish for as long as possible and expectorate. Use: Very severe cases of oral erosive lichen planus, major aphthous stomatitis, benign mucous membrane pemphigoid, and erythema multiforme. 35

Prednisolone syrup 15 mg/5 ml (Prelone) Dsp: 16 oz Sig: Take 4 tsp on awakening for 3 days, 3 tsp for 3 days, and 1.5 tsp on awakening for 3 days for long as possible and expectorate. Use: Burst therapy for very severe cases of oral erosive lichen planus, major aphthous stomatitis, benign mucous membrane pemphigoid, and erythema multiforme. 0.1% (or 0.5%) triamcinolone acetonide ointment (Kenalog®) Dsp: 15 g (80 g) tube Sig: Dry area and apply a thin film to oral sores 4 times daily (after meals and at bedtime). Do not rub in. Do not eat or drink for 1/2 hour after use. Use: Oral erosive lichen planus, bullous pemphigoid, oral pemphigus, contact (delayed) allergic stomatitis, recurrent aphthous stomatitis, chapped (cracked) lips. Note: If denture wearer, apply a thin film to inner surface of denture wherever the denture base contacts an oral lesion. 0.1% triamcinolone acetonide ointment (Kenalog) in Orabase or Orabase with benzocaine Dsp: 30 g total (15 g each) Sig: Dry area and apply a thin film to oral sores 4 times daily (after meals and at bedtime). Do not rub in. Do not eat or drink for 1/2 hour after use. Use: Oral erosive lichen planus, bullous pemphigoid, oral pemphigus, contact (delayed) allergic stomatitis, recurrent aphthous stomatitis, chapped (cracked) lips. 0.1% triamcinolone acetonide aqueous suspension Dsp: 200 ml This suspension may be compounded by a pharmacist: Add 5 ml of 95% ethanol to a vial of triamcinolone acetonide 40 mg/ml injectable and q.s. to 200 ml with sterile water OR use 40 mg triamcinolone acetonide micronized powder and dissolved in 95% ethanol and q.s. to 200 ml with sterile water. Sig: Pour 1 tsp into a clean container and then swish in mouth for 1 minute, 4 times a day (i.e., after meals and at bedtime), and expectorate. Do not pour any solution back into bottle. 36

Use: Oral erosive lichen planus, bullous pemphigoid, oral pemphigus, contact (delayed) allergic stomatitis, recurrent aphthous stomatitis. Note: Do not drink or eat for 1/2 hour after using. Shake bottle well before using. Shelf life is 6 months. A 0.2 % suspension may also be used by doubling the triamcinolone content without increasing the ethanol content. The micronization enhances topical efficacy while minimizing absorption, thus reducing concomitant systemic steroid side effects. The micronized powder choice is less expensive than Kenalog 40 mg/ml (no generic available in U.S.) and provides a much larger surface area, which results in better tissue effects. Caution: Do not allow the pharmacist to compound with sweetener and/or flavoring agents because that will reduce the contact time and probably interfere with tissue binding. 0.1% triamcinolone acetonide suspension with nystatin suspension Dsp: 200 ml Sig: Swish 1 tsp for 1 minute 4 times a day (after meals and at bedtime) and expectorate. Use: For patients predisposed to candidiasis with oral erosive lichen planus, bullous pemphigoid, oral pemphigus, contact (delayed) allergic stomatitis, recurrent aphthous stomatitis. Note: Do not drink or eat for 1/2 hour after using. Shake well before using. Shelf life is 6 months. 0.1% triamcinolone acetonide suspension in 2% viscous lidocaine Dsp: 100 ml Sig: Swish 1 tsp for 1 minute 4 times a day (after meals and at bedtime) and expectorate. Use: For patients who need immediate pain relief with oral erosive lichen planus, bullous pemphigoid, oral pemphigus, contact (delayed) allergic stomatitis, recurrent aphthous stomatitis. Note: Do not drink or eat for 1/2 hour after using. Shake well before using. Shelf life is 6 months.

37

Triamcinolone acetonide injectable 25- and 40-mg/ml suspension (Kenalog® 40 or Aristocort® 25 or 40) Sig: Following local anesthesia (to provide vasoconstriction), aspirate into an empty local anesthetic Carpule or a tuberculin syringe and multiple injections of 0.05–0.1 ml are made into the submucosa or into the bulk tissue or granuloma (i.e., inject 10–40 mg). Use: Very severe cases of oral erosive lichen planus, major aphthous stomatitis, benign mucous membrane pemphigoid, and erythema multiforme; also granulomatous swellings (e.g., cheilitis granulomatosa). Especially beneficial to manage solitary lesions recalcitrant to topical or systemic steroids. Note: Some oral pathologists advise diluting to 10 mg/ml. USED IN CONJUNCTION WITH A LOWERED DOSE OF STEROIDS Azathioprine 50 mg (Imuran®) Dsp: #30 Sig: Take 1 tablet daily in conjunction with prednisone. Use: Prescribed concomitantly with prednisone for managing severe conditions of oral erosive lichen planus, major aphthous stomatitis, benign mucous membrane pemphigoid, erythema multiforme in which the patient does not respond well to steroid alone. This combination gives the clinical effects of a higher dosage of topical or systemic steroids without their side effects. Caution: Chronic use increases the risk of nausea/vomiting, neoplasia as well as serious hematological consequences. Monitor the patient weekly and taper medications as indicated by clinical response. Discontinue if severe nausea occurs. Treatment should be in collaboration with the patient’s physician. Azathioprine should not be taken during pregnancy. A baseline CBC and liver enzyme panel should be ordered prior to starting patients on azathioprine. ALTERNATIVES TO STEROIDS 5% amlexanox oral paste (Aphthasol®) Dsp: 5 g tube Sig: Apply a small amount of paste (~1/4 inch) to the fingertip as soon as possible after noticing the symptoms of an aphthous ulcer and with gentle pressure dab onto 38

each mouth ulcer 4 times a day (after breakfast, lunch, and dinner and at bedtime following oral hygiene). Use should continue until the ulcer heals. Use: Recurrent aphthous stomatitis. Note: Advise patient not to eat or drink for 1/2 hour after application and to wash hands following use. Caution: Safety and effectiveness in pediatric patients has not been established. Clofazimine soft gelatin 50 mg capsules (Lamprene®) Dsp: #20 Sig: Take 1 tablet twice daily with meals for 10 days. Use: Off-label use for autoimmune diseases. Note: May cause discoloration of the skin. Caution: Should be used with caution in patients who have GI problems such as abdominal pain and diarrhea. Dosages greater than 100 mg daily should be given for as short a period as possible and only under close medical supervision. Colchicine 0.6 mg (VitiGam®) Dsp: #42 Sig: Take 1 tablet 3 times a day for 14 days. Use: FDA orphan drug (unlabeled/investigational) status for Behçet’s disease; selected cases of recurrent aphthous stomatitis that have not been controlled with topical or systemic steroids. Note: Can be used in combination with topical or systemic steroids. Side effects include diarrhea, neutropenia. Caution: Decreased male fertility; avoid in renal, GI, heart, or hematological disorders. Dapsone 25 mg (Avlosulfon®) Dsp: #30 Sig: Take 1 tablet daily for 3 days, then 2 tablets daily for 3 days, then 3 tablets daily for 3 days, followed by 2 tablets twice daily for 3 days. Use: Oral benign mucous membrane pemphigoid; maintenance dose after accelerated schedule is between 100 and 150 mg daily. Can be used in combination with topical and systemic steroids. Note: Patient can be worked up to 150 mg daily as needed and 100 mg tablets are available. 39

Caution: Used in consultation with patient’s primary physician. May cause hemolysis; red cell counts, hemoglobin, and hematocrit should be closely monitored (i.e., blood counts weekly for first month, monthly for 6 months and semiannually thereafter). Controversy about mucous membrane use exists. Can also cause photosensitivity. Doxycycline 100 mg (generic) Dsp: #30 Sig: Take 1 tablet daily with food and 8 oz. of water. Use: Oral benign mucous membrane pemphigoid; herpetiform aphthous stomatitis (use for 10–14 days) with chlorhexidine mouthwash twice daily. Note: An anticollagenase agent. Immune globulin, intravenous (Carimune NF®, Gammagard® liquid, Gammar P-IV®, Gamunex®, Iveegam EN®, Octagam®, Panglolubin NF®, Polygam S/D®) Dsp: Injection, powder for reconstitution Sig: Approved doses and regimens may vary between brands. Use: Off-label use for autoimmune diseases. Warning: Acute renal dysfunction can rarely occur; usually within 7 days of use; use with caution in the elderly, patients with renal disease, diabetes mellitus, volume depletion, sepsis, paraproteinemia, and nephrotoxic medications owing to risk of renal dysfunction. 2% Lidocaine (viscous) 100 ml, tetracycline oral suspension (125 mg/5ml) 18 ml, dexamethasone (0.5 mg/5 ml) 9 ml, nystatin oral suspension (100,000 IU) 73 ml Dsp: 200 ml Sig: Rinse or gargle with 2 tsp for 2 minutes 4–5 times daily. Use: Oral erosive lichen planus, bullous pemphigoid, oral pemphigus, contact (delayed) allergic stomatitis, recurrent aphthous stomatitis, chapped (cracked) lips. Methotrexate 2.5 mg Dsp: #10 Sig: Take 1 tablet weekly 40

Use: Oral erosive lichen planus, bullous pemphigoid, oral pemphigus, contact (delayed) allergic stomatitis, recurrent aphthous stomatitis. Note: Dosage may be increased as needed. Expensive; however, an injectable form is inexpensive and may be swallowed (25 mg/ml available in 10 ml vial). Caution: Used in consultation with patient’s primary physician. May cause hemolysis; red cell counts, hemoglobin, and hematocrit should be closely monitored (i.e., blood counts weekly for first month, monthly for 6 months and semiannually thereafter). Immunosuppression side effect has been reported. Misoprostol (Cytotec®) Dsp: Dosed in various microgram increments [compounded by a pharmacist] Use: Oral erosive lichen planus, bullous pemphigoid, oral pemphigus, contact (delayed) allergic stomatitis, recurrent aphthous stomatitis. Note: This medication is a prostaglandin and expensive; excellent for pain relief and increases healing rate via enhanced epithelial proliferation. Can be formulated into an insufflator (“powder puffer”),troche or occlusive ointment (e.g., clobetasol, fluocinonide). Amitriptyline may be added as a topical anesthetic. To find your nearest pharmacist who participates in the Compounding Centers of America, call 1-800-331-2498. Caution: An abortifacent and should NOT be given to women of childbearing age. Mycophenolate mofetil 250 mg and injection (CellCept®; Myfortic®) Dsp: 1 carton (4 vials); each sterile vial has 20 ml equal to 500 mg as a HCL salt Sig: Should be administered under the supervision of a physician experienced in immunosuppressive therapy. Use: Oral pemphigus vulgaris (immunosuppressant orphan drug status). Caution: Use with active peptic ulcer disease; do not administer with antacids. Warning: Risk for infection and development of lymphoproliferative disorders (particularly of the skin) are increased. Patients should limit exposure to sunlight/ 41

UV light; severe neutropenia may occur. Also, has been linked to an increased risk for first trimester pregnancy loss and increased risk for congenital malformation including particularly cleft lip/palate as well as anomalies of the distal limbs, heart, esophagus, and kidneys. Caution: Has been reported to cause progressive multifocal leukoencephalopathy in the immunocompromised patient. Pentoxifylline 400 mg (Trental®) Dsp: #90 Sig: Take 1 tablet 3 times a day with food. Use: Very severe major aphthous stomatitis especially for patients diagnosed with Behçet’s disease. Note: Therapeutic trial is 30 days. Off-label use for this blood viscosity-reducing agent. This is a secondtier option when the patient has failed to respond to sodium lauryl–free dentifrice, chlorhexidine mouth rinse, avoidance of known triggers, diazepam for stress-related recurrences, and topical and/or systemic corticosteroids. Significant side effects such as insomnia and GI upset have been reported. Sucralfate (Carafate) 6 g, tetracaine 2% (Pontocain®), 15 ml, distilled water 15 ml Dsp: 30 ml Sig: Apply to affected area as needed. Use: Oral erosive lichen planus, bullous pemphigoid, oral pemphigus, contact (delayed) allergic stomatitis, recurrent aphthous stomatitis, chapped (cracked) lips. 0.03% tacrolimus ointment (Protopic®) Dsp: 30 g (60 g) tube Sig: Dry area and apply to oral lesions 4–6 times daily (after meals and at bedtime). Do not rub in. Use: Oral erosive lichen planus, bullous pemphigoid, oral pemphigus, contact (delayed) allergic stomatitis, recurrent aphthous stomatitis, chapped (cracked) lips. Note: An immunosuppressant that may be used when first-line medications fail to resolve the condition. Caution: Use only as second-line agent for short-term and intermittent treatment in patients unresponsive to, or intolerant of, other treatments. 42

Warning: The FDA issued a public health advisory about a potential cancer risk based on animal studies and case reports in a small number of patients [2006 Black Box warning]. In 2011, the American Academy of Dermatology Advisory Task Force found no causal proof that topical immunomodulators cause lymphoma or nonmelanoma skin cancer, and systemic immunosuppression after short-term or intermittent long-term topical application seems an unlikely mechanism; however, there are still some strong debates and controversies regarding the exact indication of immunomodulators and their duration of use in the absence of active controlled trials. Tacrolimus 1.0 mg capsule (Prograf®) mixed with 1000 ml purified water—aqueous oral rinse Dsp: 1000 ml Sig: Rinse with 10 ml solution for 2 minutes, 4 times a day, expectorate. Use: Oral erosive lichen planus, bullous pemphigoid, oral pemphigus, contact (delayed) allergic stomatitis, recurrent aphthous stomatitis. Note: Shelf-life 1 month, refrigerated an immunosuppressant that may be used when first-line medications fail to resolve the condition. Caution: Use only as second-line agent for short-term and intermittent treatment in patients unresponsive to, or intolerant of, other treatments. Warning: The FDA issued a public health advisory about a potential cancer risk based on animal studies and case reports in a small number of patients [2006 Black Box warning]. In 2011, the American Academy of Dermatology Advisory Task Force found no causal proof that topical immunomodulators cause lymphoma or nonmelanoma skin cancer, and systemic immunosuppression after short-term or intermittent long-term topical application seems an unlikely mechanism; however, there are still some strong debates and controversies regarding the exact indication of immunomodulators and their duration of use in the absence of active controlled trials. Tetracycline oral suspension (125 mg/5 ml) Dsp: 100 ml Sig: Swish 5 ml for 2 minutes 4 times a day. Use: Oral nonviral soft tissue ulcerations or erosions. 43

Tetracycline oral suspension (125 mg/5 ml) 18 ml, dexamethasone elixir (0.5 mg/5 ml) 9 ml, diphenhydramine elixir (12.5 mg/5 ml) 173 ml Dsp: 200 ml Sig: Rinse mouth with 1–2 tsp for 2 minutes 4 times daily, and then expectorate. Use: Oral erosive lichen planus, bullous pemphigoid, oral pemphigus, contact (delayed) allergic stomatitis, recurrent aphthous stomatitis, chapped (cracked) lips. Tetracycline 500 mg and nicotinamide 500 mg (niacinamide) Dsp: 120 tablets of each Sig: Take 1 tablet of each 4 times a day. Use: For control of recurrent aphthous stomatitis that has failed with other therapeutic approaches or longterm steroid therapy is the only effective control; diffuse oral benign mucous membrane pemphigoid; recurrent erythema multiforme minor, and severe oral erosive lichenoid drug eruptions (the patient must stay on the eruption-causing drug). Note: Improvement usually occurs in 2–6 weeks; after 6 months, if the disease is well controlled, the dose can be tapered. Secondary candidiasis may arise. Caution: Some patients experience flushing of the skin from 2 g of nicotinamide per day. Lowering the dose to 1.5 g/day usually solves the cutaneous flushing; alternatively, 81 mg of acetylsalicylic acid taken 30 minutes prior to this preparation is reported to prevent cutaneous flushing. Special note: This is a second-tier option when the patient has failed to respond to sodium lauryl–free dentifrice, chlorhexidine mouth rinse, avoidance of known triggers, diazepam for stress-related recurrences, and topical and/or corticosteroids. Do not use time-released type of niacinamide owing to possible drug-induced hepatotoxicity. 0.1% tretinoin ointment (Retin-A®) Dsp: 20 g tube Sig: Apply lightly once daily, before bed, to the entire affected area. Use: Oral lichen planus, acne. 44

Note: Also available in 0.05%, 20 g, and 45 g tubes. Caution: Controversial use on mucous membranes. OVER-THE-COUNTER ALTERNATIVES TO STEROIDS Cimetidine 200 mg (Tagamet® HB 200) Dsp: 1 bottle Sig: Take 1 tablet 3 times daily. Use: For recurrent aphthous stomatitis that does not respond to routine management. Caution: Decreased absorption of fluconazole, ketaconazole, tetracycline; increased blood levels of metronidazole, alcohol, lidocaine, narcotic analgesics. Lactinex tablets Dsp: 1 bottle (55 tablets) Sig: Chew up and swallow with milk. Take 4 tablets 4 times a day for 4 days; then 3 tablets 4 times a day for 4 days; 2 tablets 4 times a day for 4 days; 1 tablet 4 times a day for 4 days; 1 tablet once a day for 10 days. Use: For chronic vesicular and ulcerative oral diseases. TOPICAL WOUND REPAIR Becaplermin 0.01% gel (Regranex®) Dsp: 7.5 g tube (2 g, 15 g) Sig: Apply the gel once daily in a 1/16-inch-thick layer spread evenly on the ulcerated area of the skin. Use: Adjunct to good ulcer care practices in lower extremity diabetic, neuropathic ulcers that extend into the subcutaneous tissues or beyond and have adequate blood supply. Anecdotal use in deep, slow healing ulcer of the oral cavity (i.e., traumatic granuloma). Note: Calculate the amount of gel to apply by the area (L × W) of the ulcer; as the ulcer heals, recalculate the dose at weekly or biweekly intervals. In diabetic patients likely to be bedridden or limited in activities. Caution: Nonsterile; for use in ulcers that do not heal by primary intention. Do not apply with fingers. Black box warning of increased cancer risk if use 3 or more tubes. Medihoney (80% Leptospermum honey) Dsp: 1 oz. tube Use: Wound and burn dressing. 45

VI. ANTIVIRAL AGENTS/VIRAL-BLOCKING AGENTS/ GERMICIDALS Antiviral use in children can be problematic for herpes simplex because no definitive study exists; however, prior publication of the use of acyclovir liquid in a cohort of 800 children for varicella reported no problems. Acylovir liquid (200 mg/5 ml) may be used in children for treatment of primary herpes gingivostomatitis, when administered 5 times daily for 5 days using the child’s weight in kilograms (Kg = 2.2 lb) thusly: 5–10 kg 11–15 kg 16–20 kg 21–25 kg 26–30 kg 31–35 kg >35 kg

1 4 3 8 1 2 5 8 3 4 5 8

/ tsp / tsp / tsp / tsp / tsp / tsp 1 tsp (adult dose)

Acyclovir 5% ointment (Zovirax®) Dsp: 3 g or 15 g tube Sig: Apply to skin of lip with a cotton-tipped applicator or gloved finger every 2 hours during waking hours, beginning when symptoms first occur (i.e., prodromal stage). Use: Recurrent herpes labialis (some decrease viral shedding, not pain). In primary herpes labialis, reports of decreased viral shedding and pain. Note: Apply during early (prodromal) recurrence if possible; otherwise directly over vesicles. Do not apply with exposed finger to avoid autoinoculation to other body sites (e.g., eyes) or transmission to other persons. Has an irregular performance against oral lesions; better on genital lesions, immunocompromised patients and herpes zoster patients (does not prevent postherpetic neuralgias). No generic available at this time. Acyclovir 5% ointment (Zovirax) with dyclonine HCl 1% or lidocaine 1% compound Sig: Apply to oral lesions with a cotton-tipped applicator or gloved finger every 2 hours during waking hours, beginning when symptoms first occur (i.e., prodromal stage). Use: Recurrent herpes labialis. 46

Acyclovir 5% cream (Zovirax) Dsp: 2 g tube Sig: Apply to skin of lip with a cotton-tipped applicator or gloved finger 5 times per day for 4 days, beginning when symptoms first occur (i.e., prodromal stage). Use: Recurrent herpes labialis (some decrease viral shedding, not pain). In primary herpes labialis, there are reports of decreased viral shedding and pain. Note: Apply during early (prodromal) recurrence if possible; otherwise directly over vesicles. Do not apply with exposed finger to avoid autoinoculation to other body sites (e.g., eyes) or transmission to other persons. Has an irregular performance against oral lesions; better on genital lesions, immunocompromised patients, and herpes zoster patients (does not prevent postherpetic neuralgias). No generic available at this time. Caution: Approved for patients 12 years of age and older. Acyclovir 200 mg (Zovirax or generic) [Child or Adult] Dsp: #50 or #60 Sig: Adults: Take 1 capsule 5 times daily for 10 days (primary HSV) or 5 days (recurrent HSV) OR 2 capsules 3 times a day for 10 days (primary HSV) or 5 days (recurrent HSV). Children: 20 mg/kg 5 times per day. Use: Prevention of recurrent herpes simplex infection and herpes-related erythema multiforme; varicella zoster (shingles). Note: Treatment should begin during the early stage of the recurrence in the immunosuppressed patient. The current FDA recommendation is that systemic acyclovir is used to treat oral herpes only for immunocompromised patients (until lesions are crusted over). May be used in children 2 years and older as a liquid suspension. Frontal headaches are common if patient is not adequately hydrated. Caution: Use with caution in renal function impairment, dehydration. Acyclovir 400 mg (Zovirax or generic) Dsp: #60 Sig: Take 1 capsule every 12 hours. Use: Prevention of recurrent herpes simplex infection flare-ups. 47

Note: May be indicated for patients experiencing 6 or more episodes per year. An alternate regimen is 200 mg acyclovir by mouth 3–5 times daily (see p. 47). Acyclovir 800 mg (Zovirax or generic) Dsp: #9 Sig: Take 1 capsule twice daily 1 day before dental appointment, then 1 capsule each day for 7 days. Use: Prevention of recurrent herpes simplex infection flare-ups. Note: Child: 20 mg/kg 5 times a day is an accepted dosage. Acyclovir 800 mg (Zovirax or generic) Dsp: #50 Sig: Take 1 capsule 5 times a day for 10 days. Use: Active oral herpes simplex, cytomegalovirus, hairy leukoplakia, and herpes zoster. Note: Therapy is most effective if started within 48 hours after the onset of symptoms. It is probably not indicated if the patient has been symptomatic for 7 days or longer. Patient must maintain good hydration (64 fluid oz/day). Acyclovir 5% and hydrocortisone 1% cream (Xerese®, Xerclear®) Dsp: 1 tube Sig: Apply to sore 5 times daily for 5 days. Use: Recurrent herpes labialis Note: Therapy is most effective if started within 48 hours after the onset of symptoms. It is probably not indicated if the patient has been symptomatic for 7 days or longer. Patient must maintain good hydration (64 fluid oz/day) Famciclovir 500 mg (Famvir®; generic available); also available in 125 mg and 250 mg Dsp: #21 Sig: Take 1 tablet 3 times a day for 7 days. Use: Acute herpes zoster (shingles) infection; recurrent herpes labialis (off-label use). Note: This is the prodrug of pencyclovir with approximately the same efficacy and safety as acyclovir. Equivalent to acyclovir in the duration of acute pain, but more effective for duration of postherpetic neuralgia. 48

Start soon after symptoms appear (within 48 hours), and efficacy after 72 hours is questionable. Caution: Reduce doses in renal impairment. Drug interactions with cimetidine, digoxin, and theophylline products. This medication has not been studied in children younger than 18 years old, and there are no randomized controlled studies with proof of efficacy for chronic recurrent herpes labialis. Famciclovir 500 mg (Famvir; generic available) Dsp #3 Sig: Take 3 tablets for 1 day OR 11/2 tablets twice for 1 day. Use: Recurrent herpes labialis (off-label use). Note: This is the prodrug of pencyclovir with approximately the same efficacy and safety as acyclovir. Equivalent to acyclovir in the duration of acute pain, but more effective for duration of postherpetic neuralgia. Start soon after symptoms appear (within 48 hours), and efficacy after 72 hours is questionable. Caution: Reduce doses in renal impairment. Drug interactions with cimetidine, digoxin, and theophylline products. This medication has not been studied in children younger than 18 years old. Penciclovir 1% cream (Denavir®) Dsp: 2 g tube Sig: Apply thin amount to herpetic lesion every 2 hours during waking hours for a period of 4 days. Treatment should be started as early as possible (i.e., during the prodrome or when lesions appear). Use: Recurrent herpes simplex infection (studies indicate decreased pain and mean duration of lip lesions by 1/2 day). Note: Do not apply with fingertip. No studies of primary HSV labialis or immunocompromised patients. Valacyclovir HCl 500 mg (Valtrex®; generic available) Dsp: #42 OR #14 Sig: Take 2 caplets 3 times a day for 7 days without regard to meals OR take 1 tablet twice daily for 7 days. Use: Herpes zoster (shingles) in immunocompetent individuals. 49

Note: Not for use in immunocompromised patients. A prodrug of acyclovir that is 3–5 times more bioavailable than acyclovir. More effective than acyclovir for acute pain cessation and duration of postherpetic neuralgia. Start soon after symptoms appear (48 hours), and efficacy after 72 hours is questionable. Lowest cost among prescription antivirals listed. Caution: Reduce doses in renal impairment. This medication has not been studied in children younger than 18 years old. Avoid in patients with HIV or bone marrow or renal transplants owing to risk of hemolytic-uremic syndrome. OVER-THE-COUNTER Aluminum acetate (Domeboro® astringent solution), 10% docosanol cream (Abreva) Dsp: 2 g tube Sig: Apply to herpetic lesion 5 times a day as soon as possible after detection. Use: Recurrent orofacial herpes simplex infections (i.e., cold sores, fever blisters). Caution: Local application must be done with a cottontipped applicator to prevent viral transmission and autoinoculation. Benzylalkonium chloride (Viroxyn®) Dsp: 1 kit (3 single-dose application vials) Sig: Remove cap from the vial and replace it on the other end. Hold the vial between thumb and index finger while applicator end is up. Pinch the vial in the center at the top of the cap to break inner ampule. Hold with white applicator down and allow the medication to saturate the swab. Place the applicator against the area of the lip to be treated and massage the medication into the sore by rubbing for about 10 seconds. Continue rubbing until all medication has been used. Keep the applicator saturated at all times. When finished, recap vial, and dispose immediately. Use: Recurrent herpes labialis. Note: Some patients may require a second treatment with a new vial if they experience a secondary new viral load at the same site 12–72 hours later. Prior to treatment, the lip should be clear of all other preparations; do not use soap or other cleansers (dry wipe, water, or alcohol 50

may be used). Following application, no cleaners should be used on the lip for a minimum of 1 hour. Anionic cleansers will react with and neutralize the active ingredient. Likewise, citric acid consumed within 1 hour of application could neutralize the active ingredient if it contacts the area of treatment. Caution: Do not rub the skin so vigorously that it results in damage to the skin. Some studies indicate this sterilization compound is mutagenic. Citrus bioflavonoids and ascorbic acid tablets 400 mg (Peridin-C®) Ds: #20 Sig: Take 2 tablets immediately, then 1 tablet every 4 hours for 3–4 days. Use: Recurrent herpes labialis. 2% tetracaine gel (Viractin®) Dsp: 0.25 oz. tube Sig: Apply to herpetic lesion of the lip not more than 3–4 times a day as soon as possible after detection. Use: Recurrent orofacial herpes simplex infections (i.e., cold sores, fever blisters). Caution: Local application must be done with a cottontipped applicator to prevent viral transmission and autoinoculation. A physician should be consulted for use in children younger than 2 years of age. 500 mg (Enisyl®) Dsp: #100 Sig: Take 4 tablets every 4 hours until symptoms subside. Use: Label: Improves utilization of vegetable proteins. Off-label use: Prevention of recurrent herpes simplex infection. Note: Treatment should begin during the early stage of the recurrence. May be used for up to 3 months for maintenance.

L-Lysine

VII. MUSCLE RELAXANTS Baclofen 10 mg (Lioresal®) Dsp: #60 Sig: Take 1/2 tablet 3 times daily for 3 days, then 1 tablet 3 times daily for 3 days, then 11/2 tablets 3 times daily. Use: Myogenic facial pain, tension headache. 51

Chlorzoxazone 250 mg (Paraflex®) Dsp: #100 Sig: Take 2 tablets every 4 hours. Use: Myogenic facial pain, tension headache. Chlorzoxazone with acetaminophen 500 mg tablet (Parafon® forte, generic) Dsp: #15 Sig: Take 1 tablet at bedtime. Use: Myogenic facial pain, tension headache. Note: Short-term use is recommended. This regimen can be prescribed along with NSAIDs. May take with food or milk. May cause morning hangover; dosage can be reduced in sensitive individuals. Cyclobenzaprine HCl 10 mg (Amrix®, Cycoflex®, Flexeril®; generics) Dsp: #15 Sig: Take 1 tablet at bedtime; do not crush or chew. Use: Useful for acute myogenic facial pain but questionable for chronic condition; treatment of muscle spasm associated with acute TMJ pain. Note: Short-term use is recommended (i.e., no longer than 2–3 weeks. This regimen can be prescribed along with NSAIDs. May take with food or milk. May cause morning hangover; dosage can be reduced in sensitive individuals. Cyclobenzaprine HCl extended release 15 mg capsules (Amrix; also available in 30 mg) Dsp: #15 Sig: Take 1 tablet at bedtime; do not crush or chew. Use: Useful for acute myogenic facial pain associated with but questionable for chronic condition; treatment of muscle spasm associated with acute TMJ pain. Note: Short-term use is recommended (i.e., no longer than 2-3 weeks. This regimen can be prescribed along with NSAIDs. May take with food or milk. May cause morning hangover; dosage can be reduced in sensitive individuals. Caution: Not recommended for use in the elderly. Guaifenesin 10% in speed gel Dsp:10 g 52

Sig: Rub 1–2 drops into affected area at first sign of spasm. Massage in well. Note: Has PLO gel with an additional surfactant to increase onset. Works well for locks, spasms, and cramping. VIII. ANTIANXIETY AGENTS (ANXIOLYTICS) FOR STRESS MANAGEMENT Caution for this drug class: Patients should not drive themselves to or from the dental appointment. Do not prescribe to pregnant women. Alprazolam 0.25 mg (Xanax®) Dsp: #20 Sig: Take 1 tablet 3 times daily or 1 tablet 1 hour prior to dental appointment. Use: Tension reduction prior to appointments, myogenic facial pain. Alprazolam 0.5 mg extended-release (Xanax XR®; generic available) Dsp: #20 Sig: Take 1/2 tablet 3 times daily or 1/2 tablet 1 hour prior to dental appointment. Use: Tension reduction prior to appointments, myogenic facial pain. Buspirone 5 mg (Buspar®) Dsp: #20 Sig: Take 1 tablet twice daily. Use: Tension reduction prior to appointments, myogenic facial pain. Chlordiazepoxide 10 mg (Librium®) Dsp: #20 Sig: Take 1 tablet twice daily. Use: Tension reduction prior to appointments, myogenic facial pain. Clorazepate dipotassium 7.5 mg (Traxene®) Dsp: #20 Sig: Take 1 tablet twice daily. Use: Short-term management of anxiety symptoms. 53

Diazepam 5 mg (Valium®) Dsp: #20 Sig: Take 1 tablet before bedtime a day prior to surgery, then 1 tablet 1 hour prior to surgery. Use: Tension reduction prior to appointments, myogenic facial pain. Caution: Contraindications similar to codeine. Do not use in the presence of cimetidine or any other H2-blocker. Hydroxyzine 25 mg (Atarax®) Dsp: #10 Sig: Take 2 tablets 1 hour before dental procedure. Use: Anxiety and anxiety-related skin eruptions; sedation and antiemetic action. Hydroxyzine 25 mg (Atarax) [Child] Dsp: #10 Sig: Take 1–2 tablets 1 hour before dental procedure or 0.6 mg/kg/dose every 6 hours. Use: Anxiety and anxiety-related skin eruptions; sedation and antiemetic action. Note: Children younger than 6 years should be prescribed 12.5–25 mg 1 hour before procedure. Hydroxyzine pamoate 25 mg (Vistaril®) Dsp: #20 Sig: Take 1 tablet 15–30 minutes before dental appointment. Use: Short-term relief of anxiety; sedative when used as premedication. Hydroxyzine pamoate 25 mg (Vistaril) [Child] Dsp: #20 Sig: Take 1 tablet 15–30 minutes before dental appointment or 0.6 mg/kg/dose every 6 hours. Use: Short-term relief of anxiety; sedative when used as premedication. Lorazepam 1 mg (Ativan®) Dsp: #20 Sig: Take 1 tablet daily or 1 tablet 1 hour prior to dental appointment. Use: Tension reduction prior to appointments, myogenic facial pain. 54

Prochlorperazine maleate 5 mg (Compazine®) Dsp: #20 Sig: Take 1 tablet twice daily. Use: Short-term relief of anxiety; severe nausea and vomiting. IX. ANTIDEPRESSANTS Doxepin HCl 25 mg (Sinequan®) Dsp: #45 Sig: Take 1 tablet each evening for 5 days, then 2 tablets each evening for 5 days, then 4 tablets each evening for 7 days. Use: Atypical facial pain of psychogenic origin and burning mouth syndrome; most effective in depressed patients with anxiety. Caution: Dexamethasone suppression test advisable initially. Maintenance dose varies from 100 to 200 mg daily. Fluoxetine HCl 20 mg (Prozac®) Dsp: #30 Sig: Take 1 tablet daily in the morning. Use: Atypical facial pain of psychogenic origin and burning mouth syndrome; most effective in depressed patients. Trazodone HCl 50 mg (Desyrel®) Dsp: #70 Sig: Take 2 tablets each evening for 5 days, then 3 tablets each evening for 5 days, then 3 tablets 3 times daily for 7 days. Use: Atypical facial pain of psychogenic origin and burning mouth syndrome; most effective in depressed patients. Caution: Dexamethasone suppression test advisable initially. Maintenance dose varies from 250 to 350 mg daily in divided doses. Increased risk of suicidal thinking and behavior (suicidality) associated with use in children and adolescents. X. ANALGESICS Note: NSAIDs should be taken with 8 oz of water and the patient should remain upright for at least 20 minutes 55

to help avoid gastritis side effect. NSAIDS should never be taken together, nor should they be combined with aspirin. NSAIDs have anti-inflammatory effects as well as producing analgesia. Do not use codeine in patients with history of allergy to morphine; use with extreme caution in patients with respiratory disease and hepatic disease; do not administer to patients on antidepressants, phenothiazines, or those consuming alcohol, barbiturates, and opioids. All pain medications should be prescribed for a course of no more than 3 days to avoid addiction and to re-evaluate persistent pain. Beginning in January 2011, the FDA has established a 3-year time period for drug manufacturers to limit the amount of acetaminophen to 325 mg in tablets and capsules to reduce overdoses and severe subsequent liver injury. PRESCRIPTION FOR MILD TO MODERATE PAIN Aspirin 325 mg, butalbital 50 mg, caffeine 40 mg (Fiorinal®) Dsp: #40 Sig: Take 1–2 tablets every 4 hours as needed for pain. Use: Mild to moderate pain (NSAID). Diflunisal 250 or 500 mg (Dolobid®) Dsp: #16 Sig: Take 2 tablets initially, then 1 tablet every 8–12 hours for pain. Use: Mild pain. Note: maximum dose is 1.5 g/day. Caution: Precipitates the toxicity of digoxin, anticoagulants, methotrexate, dilantin, sulphonylureas, lithium, indocin, hydrochlorothiazide, and acetaminophen, so avoid administering in their presence. Etodolac 200 mg (Lodine®) Dsp: #30 Sig: Take 1–2 tablets every 6–8 hours as needed for pain. Use: Mild to moderate pain (NSAID). Caution: Do not exceed 1200 mg/day. For patients weighing less than 60 kg, the 24-hour dose should not exceed 20 mg/kg. 56

Ibuprofen 800 mg (Motrin®) Dsp: #28 Sig: Take 1 tablet 3 times per day. Use: Mild to moderate pain (NSAID). Note: For severe pain, Motrin (800 mg) can be given up to 4 times per day. Ketoprofen 12.5 mg (Orudis®) Dsp: #30 Sig: Take 2 caplets to start, then 1 caplet every 4–6 hours, up to 6 caplets per day. Use: Mild to moderate pain (NSAID). Naproxen sodium 275 mg (Anaprox®) Dsp: #30 Sig: Take 2 tablets immediately then 1 tablet every 6–8 hours, not to exceed 5 tablets per 24 hours. Use: Mild to moderate pain (NSAID). Note: This is the prescription form of Aleve. Caution: Potential increase risk of heart attack, stroke, GI bleeding, .and allergic reactions OVER-THE-COUNTER MILD TO MODERATE PAIN Acetylsalicylic acid 325 mg (Anacin®, A.S.A., Bayer® Aspirin®, Bufferin®, Ecotrin®, Empirin®) or acetaminophen 325 mg (Tylenol®, regular strength) Dsp: 1 bottle Sig: Take 2 tablets every 6 hours as needed for pain. Use: Mild pain. Caution: Avoid aspirin in individuala with viral disease such as chicken pox (Reye’s syndrome), the elderly patient, the pregnant patient, history of platelet dysfunction, bleeding disorders, compromised renal and/or hepatic status, esophagitis, gastritis, peptic ulcer disease, and aspirin-induced asthma. Inhibits platelet aggregation and is a gastric irritant. Stop aspirin intake 7 days prior to surgery after consultation with the physician. Avoid acetaminophen in G6PD patients; toxicity will occur if patient takes 5-8g/day over several weeks. Chronic alcohol abuse can precipitate acetaminophen toxicity, and 57

avoid taking acetaminophen with alcohol. Avoid taking regular-strength acetaminophen for more than 2–3 days along with increased fluid intake in patients on coumadin. Ibuprofen 200 mg (Motrin®, Advil®, Nuprin®) Dsp: 1 bottle Sig: Take 2–4 tablets every 4 hours, up to 16 tablets per day. Use: Mild to moderate pain (NSAID). Caution: GI bleeding and bone marrow depression possible side effects. Ibuprofen (Motrin) [Child] Dsp: # 20 Sig: Take 4–10 mg/kg/dose every 6–8 hours. Use: Mild to moderate pain (NSAID). Caution: GI bleeding and bone marrow depression possible side effects. Ketoprofen 12.5 mg (Orudis KT®) Dsp: 1 bottle Sig: Take 2 caplets to start, then 1 caplet every 4–6 hours, up to 6 caplets per day. Use: Mild to moderate pain (NSAID). Naproxen sodium 275 mg (Aleve®) Dsp: 1 bottle Sig: Take 2 tablets to start, then take 1 tablet every 6–12 hours; up to 3 tablets per day. Use: Mild pain to moderate pain (NSAID). Note: Aleve is the over-the-counter form of Anaprox; same drug, same tablet size but the over-the-counter dosage is lower, duration longer, as per FDA rule. Caution: Avoid in patients with history of peptic ulcer, hepatic or renal disease, and in patients on anticoagulants. Recent questions concerning tendency to increase risk of heart attack and stroke. PRESCRIPTION FOR MODERATE PAIN Butalbital 50 mg/aspirin or acetaminophen 325 mg/ caffeine 40 mg (Fiorinal®, Fioricet®) Dsp: #40 Sig: Take 1 or 2 tablets every 4 hours as needed for pain. 58

Use: Moderate pain. Note: This regimen is useful for promoting sleep. Hydrocodone 5 mg and acetaminophen 500 mg (Lortab® 5 mg) Dsp: #20 Sig: Take 1 or 2 tablets every 4 hours for pain; do not exceed 8 tablets in 24 hours. Use: Moderate pain. Ketorolac tromethamine 10 mg (Toradol®) Dsp: #40 Sig: Take 2 tablets every 6 hours as needed for pain. Use: Moderate pain (NSAID). Oxycodone HCl 5 mg—acetaminophen 325 mg (Percocet®; generic available) or oxycodone HCl 4.5 mg—oxycodone terephthalate 0.38 mg-aspirin 325 mg (Percodan) Dsp: #20 Sig: Take 1 tablet every 4 hours as needed for pain. Use: Moderate pain. Note: Percocet is preferred for dental use. Caution: Addiction and high abuse; avoid in elderly, G6PD anemia, severe liver disease, and pulmonary disease. PRESCRIPTION FOR MODERATE TO SEVERE PAIN Acetylsalicylic acid 325 mg (Bayer Aspirin®) or acetaminophen 325 mg (Tylenol®) with #1 (Codeine 7.5 mg) #2 (Codeine 15 mg) #3 (Codeine 30 mg) #4 (Codeine 60 mg) Dsp: #20 Sig: Take 1 tablet every 4–6 hours as needed for pain. Use: Mild to moderate pain. Note: Codeine causes nausea, constipation, and sedation. Acetylsalicylic acid is not an ideal postoperative drug because it will cause excessive bleeding. Caution: Addiction side effect; do not prescribe for more than 2–3 days. Avoid #3 in G6PD patients or those taking tricyclic antidepressants, MAO-Is, and phenothiazines. Use only #1 or #2 in the elderly. 59

Celecoxib 100 mg, 200 mg, 400 mg tablets (Celebrex®) Dsp: #10 Sig: Take 400 mg followed by an additional 200 mg if needed on day 1; maintenance dose: 200 mg twice daily as needed. Use: Acute dental pain. Warning: Increased risk of cardiovascular effects, including MI, stroke, and new-onset or worsening of preexisting hypertension as for all NSAIDs. Also, do not give if recent coronary bypass graft procedure. Dihydrocodeine bitartrate 16 mg, aspirin 356.4 mg, caffeine 30 mg (Synalgos-DC®) Dsp: #10 Sig: Take 2 tablets every 4 hours as needed for pain. Use: Moderate to severe pain; sedation. Hydrocodone bitartrate 7.5 mg and acetaminophen 750 mg (Vicodin®) Dsp: #30 Sig: Take 2 tablets immediately and 1 tablet every 6 hours as needed for pain. Use: Moderate to severe pain; sedation. Caution: Do not use with MAO-Is, tricyclics, antipsychotics, antianxiety agents, other narcotics, alcohol or barbiturates; contraindicated in patients with G6PD anemia. Hydrocodone bitartrate 10 mg and acetaminophen 650 mg (Lorcet®) Dsp: #30 Sig: Take 1 tablet every 4–6 hours as needed for pain. Use: Moderate to severe pain; sedation. Hydrocodone bitartrate 7.5 mg and ibuprofen 200 mg (Vicoprofen®; Reprexain®—hydrocodone bitartrate 5.0 mg) Dsp: #45 Sig: 1–2 tablets every 4–6 hours as needed for pain. Note: Maximum of 5 tablets per day. Use: Short term (