INTERACTION BETWEEN SPECIFIC DISEASES AND DENTAL PHARMACOLOGY
Ischemic Heart Disease
Angina pectoris: Don’t give anticholinergics (Probanthine), increases cardiac rate
and oxygen demand, arrhythmias possible.
Previous myocardial infarction (MI): Don’t give aspirin or other NSAIDs for post
-op pain. If surgery and MD oks may want to be off aspirin 7-10
days pre-op.
Asthma
Attacks stimulated by aspirin, NSAIDs, barbiturates,
Narcotics and cold air.
If taking theophylline no macrolide antibiotics (Erythromycin, Azithromycin or
Clarithromycin) or Ciprofloxacin, may cause theophylline toxicity.
Antihistamines should be used with caution due to drying effects.
Local anesthetics with epinephrine or levonordefrin contain sulfite preservatives,
may cause asthma attack.
Oral candidiasis possible with steroid inhalers.
If taking oral corticosteroids for one week in last six months may be adrenal
suppressed. If stressful procedure Adrenal Supplementation Regimen is to double
normal steroid dose day of procedure and first postoperative day.
Stress may cause asthma attack. Premedication with oral diazepam ok. Nitrous
Oxide during procedure is excellent, not a respiratory depressant and doesn’t
irritate tracheobronchial tree.
Have patient bring asthma medications to appointment. Ask if any asthma
symptoms prior to dental treatment.
COPD
Avoid nitrous oxide, high oxygen flow may depress respiratory drive. Also nitrous
oxide accumulates in enlarged air spaces in lung with emphysema. If must use
oxygen use at low 2-4 liter flow rate.
Anticholinergics and antihistamines cause drying which increases mucous tenacity,
so don’t use. Narcotics and barbiturates can cause respiratory depression.
Watch for concomitant CAD and hypertension. If taking oral steroids may need to
follow Adrenal Supplementation Regimen. No office GA or IV sedation.
COPD (continued)
If taking theophylline no macrolide antibiotics (Erythromycin, Azithromycin or
Clarithromycin) or Ciprofloxacin, may cause theophylline toxicity.
Diabetes Mellitus
NPO rules for general anesthesia. Stop medications evening before surgery. Longer
acting oral agents must be stopped sooner. Glyburide (Diabeta, Micronase) stop 24
hours pre-op, Chlorpropamide (Diabinese) 36 hours and Metformin (Glucophage)
48 hours.
Bleeding Disorders, GI Disease
Avoid aspirin, aspirin compounds and NSAIDs. Use acetaminophen and codeine.
Kidney Failure
Heparin given during dialysis can cause bleeding problems. Perform dental surgical
procedures 4-30 hours after dialysis and 24-48 hours prior to next dialysis.
Avoid nephrotoxic drugs: NSAIDs, aminoglycosides, acyclovir, radiographic
contrast media. Meperidine and propoxyphene converted to renal toxic metabolites,
don’t use. Penicillin G and magnesium citrate have excessive electrolytes, don’t use.
Reduce dose of ketoconazole. Increase interval between doses with aspirin,
Acetaminophen, penicillin V, cephalexin and tetracycline.
No problems using the following drugs: Codeine, erythromycin, valium,
clindamycin and metronidazole (Flagyl).
Liver Failure
Dental drugs metabolized primarily by the liver: Local anesthetics; Lidocaine
(Xylocaine), Mepivacine (Carbocaine), Prilocaine (Citanest) and Bupivacaine
(Marcaine). Analgesics; Aspirin, Acetaminophen, Codeine, Meperidine (Demerol)
Ibuprofen (Motrin) and Propoxyphene (Darvon). Sedatives; Diazepam (Valium)
and Barbiturates. Antifungals; Ketoconazole. Antibiotics: Ampicillin, Penicillin,
Erythromycin, Clindamycin, Metronidazole and Tetracycline.
Most drugs used in dentistry metabolized by liver. Unless severe hepatic
Dysfunction can use drugs in limited quantity (Three cartridges 2% lidocaine is
108 mg, ok).
Immunocompromised
HIV+: No antibiotic prophylaxis necessary.
AIDS: Antibiotic prophylaxis.
Immunocompromised (continued)
HIV Drugs:
Protease inhibitors ritonavir (Norvir), indinavir (Crixivan), Saquinavir (Invirase)
and benzodiazepines increase benzodiazepine levels. Adjust benzodiazepine dose
or don’t use. Azole antifungals, ketoconazole, clarithromycin mixed with protease
inhibitors can be cardiotoxic with fatal arrhythmias. Produces large increases in
concentrations of meperidine and propoxyphene, don’t use with protease inhibitors.
Metronidazole and liquid ritonavir (contains alcohol) get disulfarim (Antabuse)
like reaction.
Some antihistamines) mixed with protease inhibitors can be cardiotoxic with fatal
arrhythmias.
Organ Transplant Drugs:
Follow Adrenal Supplementation Regimen if on steroids and procedure is
stressful.
Cyclosporin is hepatotoxic, neurotoxic and causes hypertension and gingival
hyperplasia.
Azathioprine (Imuran) causes hepatotoxicity, thrombocytopenia and leukopenia.
Mycophenolate (CellCept) causes leukopenia. Don’t use NSAIDs,
aminoglycosides and acyclovir with mycophenolate as causes nephrotoxicity.
Tarcolimus, a potent macrolide immunosuppressant, is nephrotoxic, neurotoxic
and diabetogenic. Macrolide antibiotics, azole antifungals and corticosteroids
Increase tarcolimus concentration.
Antihistamines terfenadine (Seldane) and astemizole (Hismanal) cause cardiac
arrhythmias when used with tacrolimus and cyclosporine.
If WBC < 2,000 need antibiotic prophylaxis.
Pregnancy
Anesthesia
No office sedation or general anesthetics. No nitrous oxide, chronic
exposure increases spontaneous abortions. Local anesthesia fine.
Acetaminophen drug of choice. Therapeutic short-term meperidine (Demerol)
And fentanyl fine. Oxy/hydrocodone not bad. Propoxyphene not good.
Codeine causes congenital anomalies.
Pregnancy
Analgesia (continued)
Aspirin causes anemia, antepartum or postpartum hemorrhage and intracranial
fetal hemorrhage. Pentazocine (Talwin) no congenital defects, but may cause
severe neonatal respiratory depression, avoid giving near term. Avoid NSAIDs
during third trimester and new research suggests throughout pregnancy.
Antibiotics
Penicillins, cephalosporins, erythromycin and clindamyacin not teratogenic.
Don’t use aminoglycosides, tetracycline, metronidazole and sulfonamides.
Corticosteroids
Increases risk of maternal infection and neonatal sepsis, don’t use.
Anticholinergics
Don’t use Pro-Banthine.
Muscle Relaxants
Cyclobenzaprine (Flexeril) one of only possible drugs to use.
Lactation
Amount of drug in breast milk usually not more than 1-2% maternal dose.
Don’t use aspirin, tetracycline, barbiturates or benzodiazepines. No consensus
on NSAIDs, oxy/hydrocodone, pentazocine and muscle relaxants, so should
probably avoid. All other drugs commonly used in dentistry ok, codeine ok,
nitrous oxide ok.
Breast feeding instructions. Instruct mother to take drugs just after breast
Feeding and avoid nursing for four or more hours after taking drugs. Pre-op
Pumping and storing milk good.
Hypothyroid
Untreated very sensitive to sedatives and opiods, use non-narcotic analgesics.
Well controlled, no treatment problems.
Adrenal Insufficiency
If taking steroids and stressful procedure follow Adrenal Supplementation
Regimen. Steroids also delay healing, cause hypertension, more susceptible
to infection.
Sickle Cell Anemia
Chronic anemia, increased severity of dentoalveolar infections, osteomyelitis,
Sickle Cell Anemia (continued)
poor healing.
Increased anesthesia risk so not good candidates for office IV.
sedation or GA.Local anesthesia without vasoconstrictor ok. If
surgery vasoconstrictor ok, aspirate well. Nitrous oxide controversial. If
use must have at least 50% oxygen, watch for diffusion hypoxia.
High dose salicylates cause acidosis. Acetaminophen and small doses of
Codeine drug of choice for pain control.
G-6-PD Deficiency
G-6-PD MED, drugs usually trigger, mostly sulfonamides, aspirin, phenacetin
and chloramphenicol. Also penicillin, streptomycin and isoniazid.
Substance Abuse
Alcohol
CNS depressant, increases effects of narcotics, benzodiazepines and
barbiturates.
Chronic users may require greater anesthetic dosages.
Avoid narcotics as often multiple addictions.
Therapeutic doses of acetaminophen mixed with alcohol may cause liver
failure.
Opiods
Medical problems include liver disease and infectious diseases (HIV,
infectious hepatitis and endocarditis). Intravenous drug use history, consider
antibiotic prophylaxis.
High tolerance to pain medication, difficult IV access, behavior problems
and higher dose requirements of anesthetic agents. If on methadone, take
pre-op. Droperidol good for dissociative effect.
Avoid narcotic antagonists, may cause withdrawal (Talwin NX). Can
develop profound hypotension during IV sedation and GA.
Heroin causes xerostomia, cervical caries.
Management principals: Agree prior to procedure on type and time on
narcotics. If cured addict (any substance) avoid narcotics, NSAIDs
preferred.
Seizure Disorder
Phenytoin, carbemazepine and valpoic acid may cause leukopenia and
thrombocytopenia. Don’t use NSAIDs with these medications. No
propoxyphene or erythromycin with carbemazepine.
Stroke
Coumadin monitor by PT or INR.
Aspirin or antiplatelet drugs (dipyridamole) monitor by bleeding time: >10
minutes, slightly increased bleeding risk, >20 minutes, significant bleeding risk.
Arthritis
Aspirin and NSAIDs watch for bleeding.
If rheumatoid arthritis may be taking gold salts, penicillamine,
immunosuppressives or sulfasalazine causing stomatitis.
If stomatitis with bleeding and ulceration watch for blood dyscrasias; anemia,
agranulocytosis or thrombocytopenia.
If steroids may need supplementation.
If joint prosthesis antibiotic prophylaxis.
Allergies and Congestion
Antihistamines have additive CNS depression with CNS depressants and
alcohol. Increased anticholinergic effects with anticholinergics and other
antihistamines.
Don’t use ketoconazole or erythromycin with antihistamines, can result in liver
damage and cardiac arrhythmias with possible fatalities.
No arrhythmias reported with loratadine (Claritan), fexofenadine (Allegra),
clemastine (Tavist), diphenhydramine (Benadryl), meclizine (Antivert).
Reported problems with cetirizine (Zyrtec).
Decongestants, don’t use local anesthetic with vasoconstrictor, can cause
pressor response. Sedation with CNS depressants and Alcohol. Arrhythmias
with inhalation anesthetics.Medications include Pseudoephedrine (Sudafed,
Actifed Tabs, Afrin Tabs, Triaminic), Oxymetazoline (Afrin) and Ephedrine.
VASOCONSTRICTORS
Cardiovascular Disease
Healthy adult can receive up to 0.2 mg of epinephrine within 15 minutes. Each c.c.
of 1:100,000 epinephrine contains 0.01 mg. Carpule is 1.8cc, so contains 0.018 mg.
No more than 10 carpules in 15 minutes.
Vasoconstrictor Precautions: With cardiovascular disease limit to 0.04 mg
epinephrine or 0.2 mg levonordefrin in 15 minutes, no more than 2 carpules.
With cardiovascular disease don’t use gingival retraction cord containing
epinephrine. Don’t use 1:50,000 epinephrine. Avoid intraligamental and
intraboney injections with vasoconstrictor local anesthetics.
Avoid vasoconstrictors if taking noncardioselective beta-blockers: Carteolol
(Cartrol, Ocupress), Carvedilol (Coreg), Nadolol (Corgard), Penbutolol (Levatol),
Pindolol (Visken), Propranolol (Inderal) and Timolol (Blocadren). Can use
1:100,000 epinephrine if monitor pre and post injection vital signs, give ½ carpule,
wait 5 minutes, if no change can repeat process. Can use levonordefrin in same
manner.
If patient taking Digoxin (Lanoxin) check with physician prior to using
vasoconstrictor.
Arrhythmia
Same Vasoconstrictor Precautions except if serious arrhythmia don’t use
vasoconstrictor in local anesthetic.
Psychiatric Disorders
Potential for hypertensive crisis, myocardial infarction mixing vasoconstrictors
with neuroleptic and heterocyclic medications.
Neuroleptic agents (Antipsychotic drugs) are Chlorpromazine (Thorazine),
Fluphenazine (Permitil), Trifluoperazine (Stelazine), Mesoridazine (Serentil),
Haloperidol (Haldol), Molindone (Moban). If patient is not acutely hypotensive
due to these medications and can avoid intravascular injections, can use
vasoconstrictors in normal dosages. Hypotensive reaction can result from alpha
adrenergic blockade and increase epinephrine results in only beta-2 vasodilative
effects.
Heterocyclics (TCAs) are Amitriptyline (Elavil), Imipramine (Tofranil),
Amoxapine (Asendin), Maprotiline (Ludiomil). If use 1:100,000 epinephrine give
no more than 1/3 maximum dose. Additional dosages after 30 minutes. Don’t use
levonordefrin (Carbocaine with Neocobefrin). Some gingival retraction cords
contain large amounts of epinephrine, don’t use.
Psychiatric Disorders (continued)
MAO inhibitors are Phenelzine (Nardil), Isocarboxazid (Marplan) and
Tranylcypromine (Parnate). Use local anesthesia without vasoconstrictor
whenever possible. If must use limit to two carpules 1:100,000 epinephrine
within 15 minutes, aspirate.
Substance Abuse
Stimulants, Cocaine and Methamphetamine
Local anesthesia with vasoconstrictor can cause life threatening arrhythmias and
hypertensive crisis. General anesthetics can be dangerous as are mixing with
psychotropic drugs.
Miscellaneous Vasoconstrictor Interactions
Don’t use vasoconstrictor if patient has:
1. Pheochromocytoma
2. Hyperthyroid
3. Significant risk with phenylephrine (OTC cold medication)
4. Phentermine (Fastin)
5. Ritalin if patient is hypertensive
Use with caution if:
1. General anesthetic agents; Halothane (Fluothane), Enflurane (Etharane),
Isoflurane (Forane) and Thiopental (Pentothal). Check with anesthesiologist
to see if can use and in what amounts.
2. Guanethidine (Ismelin) and Guanadrel (Hylorel) antihypertensives follow TCA
precautions.
Dental Drug Interactions
Antibiotics
Penicillin Derivatives: Tetracyclines, erythromycin and clindamycin decrease
effectiveness. Acts synergistically with aminoglycosides. Probenecid will increase
blood levels.
Penicillin, Amoxicillin, Ampicillin, (Augmentin), and (Unasyn)
Macrolide: Decreases action of clindamycin, penicillins and oral contraceptives.
Increases effects of oral anticoagulants and benzodiazepines. Medical; increases
effects of alfentanil, carbamazepine, theophylline, felodipine, triazolam and
ergotamine. Contraindicated with azole antifungals, statins, theophylline,
(Erythromycin and Clarithromycin).
Erythromycin, Clarithromycin (Biaxin) and Azithromycin (Zithromax)
Lincomycin Derivatives: Decreases activity of erythromycin, increases activity of
nondepolarizing muscle relaxants and hydrocarbon inhalation anesthetics.
Clindamyacin (Cleocin)
Cephalosporins: Decreased bactericidal effects with tetracyclines and erythromycin.
May reduce effectiveness of oral contraceptives. Probenecid decreases elimination.
Cephalexin (Keflex, Keftab)1st generation
Cefadroxil (Duricef) 1st generation
Cefprozil (Cefzil)2nd generation
Cefuroxime (Ceftin)2nd generation
Cefaclor (Ceclor)2nd generation
Loracarbef (Lorabid)2nd generation
Cefpodoxime (Vantin)2nd generation
Cefixime (Suprax)3rd generation
Tetracycline Derivatives: Decreases effect of penicillin, cephalosporin, oral
contraceptives. Increases oral anticoagulant effect. Absorption reduced by dairy
products, calcium, magnesium or aluminum containing antacids, iron, zinc, and
cimetidine. Outdated drug can cause nephropathy. If give with Methoxyflurane
anesthesia can cause fatal nephrotoxicity.
Tetracycline (Achromycin, Sumycin, Tetracyn)
Minocycline (Minocin)
Doxycycline (Vibramycin)
Tetracycline Periodontal Fibers (Actisite)
Antifungals
Fluconazole (Diflucan)
Increases coumadin and benzodiazepine activity. Rifampin decreases fluconazole
activity. Arrhythmias possible with antihistamines.
Metronidazole (Flagyl)
None with Disulfiram (Antabuse), causes psychosis.
Clotrimazole (Mycelex Troche)
Increases activity of cyclosporines and sulfonylureas.
Antivirals
Acyclovir (Zovirax)
Increased CNS side effects with zidovudine (AIDS drug) and probenecid.
Non-Narcotic Analgesic
Non-Steroidal Anti-inflammatory Drugs (NSAIDs)
Salicylate NSAIDs
Increases bleeding risk with oral anticoagulants. Avoid corticosteroids and
Acetaminophen. Can cause toxicity of Diamox (CNS) and methotrexate (hepatic).
Increased GI bleeding and complaints with alcohol. Increased risk bleeding valproic
acid, dipyridamole. Increased toxicity lithium and zidovudine. Decreased effects
of probenecid and sulfinpyrazone.
Acetylsalicylic Acid (Aspirin, Anacin, Bayer, Bufferin, Ecotrin,
Empirin)
Propionic Acid Derivative NSAIDs
Same as salicylates. Nephrotoxic with acetaminophen. Increased photosensitivity
with tetracycline. Increased toxicity diuretics. Not with methotrexate.
Ketoprofen (Orudis, Oruvail)
Oxaprozin (Daypro)
Naproxen (Aleve, Anaprox, Naprosyn)
Ibuprofen (Advil, Motrin, Midol, Nuprin, Rufen)
Acetic Acid Derivative NSAIDs
Same as other NSAIDs plus decreases antihypertensive effects beta-blockers,
hydralazine and captopril. Increases serum potassium of potassium sparing
Diuretics. Nephrotoxic with cyclosporine. Increases toxicity of digoxin and
Aminoglycosides. Probenecid increases this medications serum concentration. Not
with lithium or methotrexate.
Acetic Acid Derivative NSAIDs (continued)
Indomethacin (Indocin)
Diclofenac (Cataflam, Voltaren)
Nabumetone (Relafen)
Etodolac (Lodine)
Sulindac (Clinoril)
Other NSAIDs
Diflunisal (Dolobid)
Decreased effect with antacids. Increased toxicity with digoxin, methotrexate,
anticoagulants, phenytoin and sulfonylureas. Increased toxicity with sulfonamides,
indomethacin, hydrochlorothiazide, lithium and acetaminophen.
Piroxicam (Feldene)
GI ulcer, bleeding with aspirin, alcohol and corticosteroids. Nephrotoxicity with
Acetaminophen (prolonged use, high dose). Decreased action salicylates. Risk of
increased effects oral anticoagulants, oral antidiabetics, lithium and methotrexate.
Decreased antihypertensive effects of diuretics, B-adrenergic blockers and ACE
inhibitors. Decreased effect with aspirin, antacids and cholestyramine.
Mefenamic Acid (Ponstel)
Increases effects of oral anticoagulants. Decreased effect with aspirin. None with
corticosteroids, methotrexate and lithium.
Cox-2 Inhibitors
Don’t use with aspirin, increased activity of oral anticoagulants. Other reactions
Same as other NSAIDs.
Celecoxib (Celebrex)
Rofecoxib (Vioxx)
Para-aminophenol Derivates
Barbiturates liver toxicity of high doses of acetaminophen. Therapeutic doses with
alcohol may cause severe hepatic toxicity. Nephrotoxicity with long-term
consumption especially if combined with NSAIDs. Buffered acetaminophen
decreases tetracycline absorption. Cholestyramine reduces effect. Hepatic toxicity
possible with INH and Dilantin.
Acetaminophen (Tylenol, Aspirin Free Anacin, Tempra)
Non-Narcotic Analgesic?
Tramadol (Ultram)
Increased risk respiratory depression with anesthetics and alcohol. Increased risk
sedation with other CNS depressants and alcohol. Decreased activity with
carbamazepine. Increased activity with cimetidine and quinidine. Increased risk of
seizures MAO inhibitors, TCAs and serotonin reuptake inhibitors.
Narcotic Analgesic
Opium Alkaloid +
Hydrocodone and Acetaminophen (Anexia, Bancap, Co-Gesic, Lorcet, Lortab and Vicodin)
*Hydrocodone and Acetaminophen
*Allergic cross reactions with other phenanthrene derivatives (morphine, codeine,
levorphanol, oxycodone and oxymorphone). Increased CNS depression with alcohol,
phenothiazines, sedative/hypnotics, skeletal muscle relaxants, general anesthetics and
other opiods. Increased effects of anticholinergics, may cause paralytic ileus.
Use of antidepressants (MAO inhibitors or TCAs) and hydrocodone can increase
effects of both antidepressant and hydrocodone.
Hydrocodone and Aspirin (Lortab ASA)
Same drug interactions as individual components.
Acetaminophen and *Codeine (Capital and Codeine, Phenaphen with Codeine, Tylenol with Codeine)
*Similar drug interactions as individual components. Codeine acts as hydrocodone.
Acetaminophen and *Oxycodone (Percocet, Tylox)
*Class II narcotic. Same drug interactions as individual components with Oxycodone acting as Hydrocodone
Aspirin and Oxycodone (Percodan)
Same drug interactions as individual components, with Oxycodone acting as codeine.
Synthetic, Meperidine Group