Important Drugs in Dental Care
The most critical drugs in dental practice fall into four categories: local anesthetics for pain control, antibiotics for infection management, analgesics for post-procedural pain, and antiseptics for infection prevention.
Local Anesthetics
Articaine with epinephrine (1:200,000) is the primary local anesthetic used in dental procedures, providing onset of anesthesia within 1-6 minutes and complete anesthesia lasting approximately 1 hour. 1
- Lidocaine and mepivacaine are safe alternatives, particularly in patients with renal failure 2
- Epinephrine-containing formulations have minimal cardiovascular effects in controlled hypertensive patients, though blood pressure monitoring is essential 2
- The vasoconstrictor epinephrine slows systemic absorption and prolongs anesthetic duration by 3-5 fold 1
Important caveat: Avoid epinephrine-containing anesthetics in patients taking nonselective beta-blockers (like propranolol), as this can cause severe hypertensive reactions and reflex bradycardia due to unopposed alpha-adrenergic stimulation 3
Antibiotics for Dental Infections
Amoxicillin 500 mg three times daily for 5-7 days is the first-line antibiotic for dental infections in non-allergic patients. 4, 5
- Phenoxymethylpenicillin serves as an alternative first-line option, particularly for apical abscesses 2, 4
- For penicillin-allergic patients, clindamycin 300-400 mg three times daily for 5-7 days is the primary alternative 4, 5
- Azithromycin may be considered when clindamycin is contraindicated 4
- For chronic periodontitis, amoxicillin/metronidazole combination as adjunct to scaling shows superior outcomes 2
Critical principle: Antibiotics should ONLY be prescribed as adjuncts to surgical intervention—never as substitutes—as up to 80% of antibiotics prescribed by dentists are potentially unnecessary 4, 5
Specific Indications for Antibiotics
Antibiotics are indicated ONLY when:
- Systemic involvement is present (fever, malaise, lymphadenopathy, cellulitis) 5
- Progressive infection extends into cervicofacial tissues or facial spaces 5
- Diffuse swelling cannot be adequately drained 5
- Patient is medically compromised or immunosuppressed 5
Do NOT prescribe antibiotics for:
- Acute apical periodontitis without systemic involvement 2, 4
- Irreversible pulpitis 2, 5
- Chronic periodontitis (except sub-antimicrobial dose doxycycline) 2, 5
- Routine post-extraction prophylaxis in healthy patients 5, 6
Antibiotic Prophylaxis for Infective Endocarditis
For patients at high risk of infective endocarditis, prescribe amoxicillin 2 g orally 1 hour before dental procedures. 4, 5
- For penicillin-allergic patients, clindamycin 600 mg orally 1 hour before the procedure 2, 4, 5
- In hemodialysis patients, amoxicillin 2 g should be given 1 hour before treatment 2, 4
- Dose adjustments are required for patients with renal impairment 4, 5
Analgesics for Pain Management
NSAIDs are the first-line pharmacotherapy for dental pain, superior to acetaminophen alone. 5, 7
- Ibuprofen and other NSAIDs provide effective post-procedural analgesia 7
- Acetaminophen (paracetamol) is an option but NSAIDs are preferred 5
- For temporomandibular disorder (TMD) pain, NSAIDs are first-line, with neuromodulatory medications (amitriptyline, gabapentin) reserved for chronic cases 5
Critical drug interaction: NSAIDs inhibit renal excretion of lithium, leading to lithium toxicity—avoid this combination 3
Opioid Considerations
- Opioids should be reserved for severe pain not controlled by NSAIDs 7
- In chemically dependent patients, extended-release morphine (MS Contin) has been used with variable success 8
- Adequate pain control is essential in recovering chemically dependent patients, as unrelieved pain can trigger relapse 8
Antiseptics and Topical Agents
Chlorhexidine gluconate 0.12-0.2% mouthwash is the gold standard for oral antisepsis, used for gingivitis, periodontitis, and pre/post-surgical care. 2, 4
- Patients should rinse with chlorhexidine for 3 minutes before surgery 2
- Chlorhexidine reduces oral microorganisms in aerosols during procedures, though evidence for preventing clinical infections is inconclusive 2
- For post-radiation patients (≥50 Gy), chlorhexidine 0.12% or 0.2% twice daily until adequate healing 6
Topical Anesthetics
- Benzocaine gel/spray (20%) provides temporary relief of oral pain 4
- Lidocaine viscous (2%) is an alternative topical anesthetic 4
Special Medication for Chronic Periodontitis
Sub-antimicrobial dose doxycycline (20 mg twice daily for 3-9 months) as adjunct to scaling and root planing is the ONLY antimicrobial with demonstrated benefit in chronic periodontitis. 2, 4, 5
- This regimen shows significant reduction in probing depth (0.9 mm) and clinical attachment level gain (0.88 mm) at nine months 2
- Standard antibiotic doses are NOT indicated for chronic periodontitis 5
Critical Drug Interactions in Dental Practice
Metronidazole and fluconazole dramatically increase INR in patients taking warfarin by inhibiting CYP-2C9, potentially causing fatal bleeding. 3
- Avoid metronidazole in warfarin patients or arrange close INR monitoring 3
- Propranolol and nonselective beta-blockers with epinephrine cause hypertensive crises 3
- NSAIDs with lithium cause lithium toxicity 3
Sedation Medications
Benzodiazepines are the drugs of first choice for oral sedation in dental care. 9
- Diazepam 0.1-0.8 mg/kg body weight (higher doses in children, lower in elderly) 9
- Indicated for alleviating mild anxiety, avoiding treatment stress, and facilitating sleep before treatment 9
- Particularly useful for medically poor-risk patients with cardiovascular disease 9
Infection Control Medications
Use single-dose vials for parenteral medications whenever possible, and never administer medication from a syringe to multiple patients, even if the needle is changed. 2