What medications are commonly prescribed by dentists in Canada?

Commonly Prescribed Medications by Dentists in Canada

Dentists in Canada most commonly prescribe antibiotics (amoxicillin and penicillin V as first-line), NSAIDs (ibuprofen) for pain management, and occasionally opioid combinations for severe post-operative pain, though antibiotics should only be used as adjuncts to surgical treatment and never as substitutes for definitive dental care. 1, 2

Antibiotics for Dental Infections

Amoxicillin 500 mg three times daily for 5-7 days is the first-line antibiotic choice for dental infections in non-allergic patients. 2

• Phenoxymethylpenicillin (Penicillin V) serves as an alternative first-line option, particularly for apical abscesses requiring antibiotic therapy 2
• For penicillin-allergic patients, clindamycin 300-400 mg three times daily for 5-7 days is the primary alternative 2
• Azithromycin may be considered when clindamycin is contraindicated 2

Critical Prescribing Principles for Antibiotics

Antibiotics must only be prescribed as adjuncts to surgical intervention—never as substitutes—as this approach is ineffective and drives antimicrobial resistance. 1

• Antibiotics are indicated only when systemic involvement is present: fever, malaise, lymphadenopathy, or cellulitis 1
• Medically compromised patients (immunosuppressed, diabetic, or requiring cardiac prophylaxis) warrant antibiotic coverage 1
• Progressive infection extending into cervicofacial tissues or facial spaces requires antibiotic treatment 1
• Diffuse swelling that cannot be adequately drained is an indication for antibiotics 1

Common pitfall: Up to 80% of antibiotics prescribed by dentists are potentially unnecessary—never prescribe for irreversible pulpitis, chronic periodontitis, or routine post-extraction prophylaxis in healthy patients. 1, 2

Pain Management Medications

NSAIDs as First-Line Analgesics

Ibuprofen 400-600 mg is the most effective first-line analgesic for dental pain, superior to opioid-acetaminophen combinations for moderate to severe pain. 3, 4, 5, 6

• Ibuprofen 400 mg provides excellent pain relief through anti-inflammatory and analgesic action 3, 4
• Ibuprofen 600 mg and 800 mg formulations are available for more severe pain 3
• Naproxen 400-440 mg is an alternative NSAID with comparable efficacy 6
• NSAIDs should be prescribed on a fixed schedule (not "as needed") to prevent breakthrough pain 5

Combination Analgesics

The combination of ibuprofen 400 mg plus acetaminophen 1000 mg provides superior pain relief compared to either agent alone and is more effective than most opioid combinations. 7, 8, 6

• Ibuprofen 200 mg plus acetaminophen 500 mg is effective for moderate pain 8, 6
• This combination demonstrated significantly better efficacy than comparable doses of monotherapy in post-extraction pain 7, 8
• The combination shows no pharmacokinetic interaction between the two drugs 7

Opioid-Containing Analgesics

Opioids should be reserved for severe pain only, as most formulations (except acetaminophen 650 mg plus oxycodone 10 mg) provide no better pain relief than placebo in dental pain. 6

• Acetaminophen 650 mg plus oxycodone 10 mg is the only opioid combination with moderate-to-high certainty evidence for efficacy 6
• Codeine 60 mg, oxycodone 5 mg alone, and tramadol 37.5 mg plus acetaminophen 325 mg were no better than placebo 6
• Tramadol has centrally acting opioid properties with mean peak plasma concentration at 2-3 hours, but limited efficacy data for dental pain 9
• Common pitfall: Prescribing weak opioid combinations (codeine, low-dose tramadol) that provide no meaningful benefit while exposing patients to opioid-related risks 6

Antibiotic Prophylaxis for High-Risk Patients

For patients at high risk of infective endocarditis undergoing dental procedures, prescribe amoxicillin 2 g orally 1 hour before the procedure. 2

• For penicillin-allergic patients, clindamycin 600 mg orally 1 hour before the procedure is recommended 2
• This applies only to high-risk cardiac patients, not routine prophylaxis 2

Topical Medications

Chlorhexidine gluconate 0.12-0.2% mouthwash is indicated for gingivitis, periodontitis, and pre/post-surgical oral antisepsis. 2

• Benzocaine gel/spray (20%) and lidocaine viscous (2%) provide temporary relief of oral pain 2
• These are adjuncts to definitive treatment, not substitutes 2

Temporomandibular Disorder (TMD) Pain Management

NSAIDs are the first-line pharmacotherapy for TMD pain, with neuromodulatory medications (amitriptyline, gabapentin) reserved for chronic cases. 10, 1

• Acetaminophen (paracetamol) is listed as an option but NSAIDs are preferred 10
• Conservative approaches including jaw exercises, heat/cold application, and behavioral therapy should accompany pharmacotherapy 10

Special Populations

Patients with renal impairment require dose adjustments for most antibiotics; patients on hemodialysis should receive amoxicillin 2 g one hour before dental treatment. 2

• Approximately 7% of the population are CYP2D6 poor metabolizers, resulting in altered tramadol metabolism with 20% higher tramadol concentrations and 40% lower active metabolite (M1) concentrations 9
• Concomitant use of CYP2D6 inhibitors (fluoxetine, paroxetine, quinidine) with tramadol can result in significant drug interactions 9

Chronic Periodontitis Exception

Sub-antimicrobial dose doxycycline (20 mg twice daily for 3-9 months) as an adjunct to scaling and root planing is the only antimicrobial with demonstrated benefit in chronic periodontitis. 1

• This is the sole indication where antimicrobials have proven efficacy in chronic periodontal disease 1
• Standard antibiotic doses are not indicated for chronic periodontitis 1