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CHAPTER 18 DENTAL PRESCRIBING Alphabetical list of products 18 Introduction 18.1 Joint Formulary recommended DPF drugs 18.3 Respiratory 18.4 Central nervous system 18.5 Infections 18-5
BNF 22.214.171.124 Benzylpenicillin and phenoxymethylpenicillin
BNF 5.1.2 Cephalosporins, cephamycins and other beta-lactams 18-5 BNF 5.1.3 Tetracyclines
18.9 Nutrition and blood 18.10 Musculoskeletal and joint diseases
BNF 10.1.1 Non-steroidal anti-inflammatory drugs
18.12 Ear, nose and oropharynx
BNF 12.3.1 Drugs for oral ulceration and inflammation 18-7 BNF 12.3.2 Oropharyngeal anti-infective drugs
BNF 12.3.4 Mouthwashes, gargles and dentifrices
BNF 12.3.5 Treatment of Dry Mouth 18-9 18.13 Skin 18-9
BNF 13.4 Topical corticosteroids 18-9 BNF 13.10.1 Antibacterial preparations 18-9 BNF 13.10.3 Antiviral preparations 18.9 Appendix 1 Children's doses for commonly prescribed medications 18-10 Appendix 2 Prevention of endocarditis in patients with heart-valve lesion, septal defect, patent ductus, prosthetic valve, or history of endocarditis 18-11
First line drugs Second line drugs Specialist drugs Hospital only drugs Alphabetical list of products
Sugar Free Suspensions are preferred if available and preparations are identified by SF. Ensure prescriptions state ‘sugar free’ as alternatives may be available.
Aciclovir 18-6, Erythromycin ethyl succinate 18-6 Adcortyl in Orabase® 18-8 Fluconazole 18-6 Amoxicillin 18-5 Glandosane® not SDJF 18-9 Amphoteracin not PAJF 18-8 Hydrocortisone 18-8, Artificial Saliva (Luborant®) Hydrocortisone and Miconazole 18-10 not SDJF 18-9 Hydrogen peroxide 18-9 Artificial saliva Substitutes 18-9 Ibuprofen 18-7 Ascorbic Acid not SDJF 18-7 Menthol and eucalyptus 18-4 Aspirin 18-4 Metronidazole 18-6 Azithromycin 18-6 Miconazole 18-8 Benzydamine 18-8 Mouthwash solution 18-9 Biotene Oralbalance 18-9 Nystatin 18-8 Carbamazepine 18-5 Oxytetracycline 18-5 Carmellose not SDJF 18-8 Paracetamol 18-4 Cefalexin 18-5 Phenoxymethylpenicillin 18-5 Chlorhexidine gluconate 18-9 Promethazine 18-4 Chlorphenamine 18-4 Sodium chloride 18-9 Choline salicylate 18-8 Sodium fluoride 18-6 Clindamycin 18-6 Sodium fusidate not PAJF 18-10 Diazepam 18-4 Temazepam 18-4 Dihydrocodeine 18-5 Triamcinolone 18-8 Doxycycline 18-5 Vitamin B Compound Strong 18-7 Erythromycin 18-5 Non formulary items (i.e. items on DPF but excluded from Joint Formularies) First line drugs Second line drugs Specialist drugs Hospital only drugs 18 Introduction A Joint Venture – A Joint Formulary The South Devon and Plymouth Joint Formularies are produced as joint ventures between primary and secondary care. This means that primary and secondary care prescribers and clinicians, community and secondary care pharmacists and Primary Care Trust prescribing teams all have an input into the production of each chapter of the Joint Formularies, either by feeding back on wide consultation or being directly involved in the Joint Formulary Groups. This chapter has also been produced as a joint venture by the formulary teams of South Devon and Plymouth Area. Variations in drug choices between the two formularies are marked with not SDJF for drugs not recommended in South Devon and not PAJF for those not recommended in Plymouth Area. Aims of a Joint Formulary The Joint Formularies have been designed as advisory tools to assist in promoting safe, cost-effective prescribing within the South Devon and Plymouth Area. It is hoped that the Joint Formularies will cover 80%-90% of prescribing within the health communities and we recognise that there will be instances where prescribing outside of the formulary will be both necessary and appropriate. For example, new patients registering with a practice on a non- formulary drug; specialised usage of a drug within secondary care. Please refer to the relevant chapters for full notes on individual drugs.
For information on medical emergencies and medical problems in dental practice, refer to section on ‘Prescribing in dental practice’ at the front of the BNF. Abbreviations used: PAJF = Plymouth Area Joint Formulary SDJF = South Devon Joint Formulary First line drugs Second line drugs Specialist drugs Hospital only drugs 18.1 Joint Formulary recommended DPF drugs 18.3 Respiratory BNF 3.4.1 Antihistamines Chlorphenamine Promethazine hydrochloride Note: Promethazine may be a useful alternative to benzodiazepines for sedation. However, residual sedation may occur the following day and its sedative effects may diminish after a few days of continued treatment. BNF 3.8 Aromatic inhalations Menthol and eucalyptus 18.4 Central nervous system BNF 4.1.1 Hypnotics Temazepam Notes: 1. Temazepam is a Schedule 3 controlled drug but is exempt from prescription and
2. Nitrazepam is not recommended due to its long duration of action. BNF 4.1.2 Anxiolytics Diazepam BNF 4.7.1 Non-opioid Analgesics Aspirin Paracetamol Notes: 1. Paracetamol is usually the simple analgesic of choice. 2. Dispersible preparations should be reserved for patients who cannot swallow solid
tablets per day of soluble paracetamol may increase intake of sodium chloride by 8g daily. This may be a significant risk in patients with heart failure or hypertension. BNF 4.7.2 Opioid analgesics Dihydrocodeine BNF 4.7.3 Neuropathic pain Carbamazepine First line drugs Second line drugs Specialist drugs Hospital only drugs 18.5 Infections BNF 126.96.36.199 Benzylpenicillin and phenoxymethylpenicillin Phenoxymethylpenicillin BNF 188.8.131.52 Broad-spectrum penicillins Amoxicillin Note: Ampicillin is not included in the joint formularies. Amoxicillin has a similar antibacterial spectrum and is better absorbed. BNF 5.1.2 Cephalosporins, cephamycins and other beta- lactams Cefalexin Notes: 1.
The capsule preparation of cefalexin is less expensive than tablet form.
Cefalexin is a more cost effective alternative to cefradine in primary care. Cefradine is not included in SDJF.
BNF 5.1.3 Tetracyclines Oxytetracycline Doxycycline Notes: 1. Oxytetracycline is a suitable alternative to tetracycline, which has not been included. 2. Doxycycline tablets 20mg have not been included because they are not commonly BNF 5.1.5 Macrolides Erythromycin Erythromycin ethyl succinate Notes: 1. Macrolides are indicated in patients with a penicillin allergy in primary care. 2. There is little evidence to suggest that any erythromycin salt is superior in terms of
clinical effect (safety or efficacy) and for this reason generic enteric-coated erythromycin tablets are recommended. (DTB 1995; 33:77-79). Erythromycin stearate tablets are less commonly prescribed and more expensive. First line drugs Second line drugs Specialist drugs Hospital only drugs BNF 5.1.6 Clindamycin Clindamycin Note: Clindamycin is implicated with over growth of Cl. difficile which limits its use. Clindamycin is associated with serious side effects. The most toxic effect is antibiotic-associated colitis which is most common in middle-aged and elderly women especially following an operation. May be fatal. Patients should discontinue treatment immediately if diarrhoea develops. BNF 5.1.11 Metronidazole Metronidazole BNF 5.2 Antifungal drugs Fluconazole Note: Amphoteracinnot PAJF, miconazole and nystatin are included in section 12.3.2. BNF 5.3.2 Herpesvirus infections Aciclovir
Tablets 200mg (Cream see section 13.10.3) 18.9 Nutrition and blood BNF 9.5.3 Fluoride Sodium fluoride Notes: 1. Dental surgeons should be aware of the level of fluoride in the water supply of the
patient’s home before prescribing this treatment.
2. Fluoride is not added to Devon or Cornwall’s water supplies. Both supplies contain a
source of naturally occurring fluoride (100 micrograms/litre).
3. It is now considered that the topical action of fluoride on enamel and plaque is more
important than the systemic effect of fluoride.
4. Some children with medical conditions (e.g. heart defects) or a family history of tooth
decay may benefit from fluoride supplements.
5. Advised dosages of fluoride supplementation (BNF 51, March 2006):
First line drugs Second line drugs Specialist drugs Hospital only drugs Water content <300 micrograms Water content >300 micrograms, F-/litre <700 micrograms F-/litre 18.10 Musculoskeletal and joint diseases BNF 10.1.1 Non-steroidal anti-inflammatory drugs Ibuprofen
1. Ibuprofen remains the first line NSAID. If a patient says that they have tried ibuprofen
check that they have taken an anti-inflammatory dose i.e. at least 400 mg TDS, regularly.
2. The CSM advises that ibuprofen is associated with the lowest risk of serious upper
18.12 Ear, nose and oropharynx BNF 12.2.2 Topical nasal decongestants Note: Sodium Chloride is a suitable alternative to ephedrine nasal drops, which are not included. Sympathomimetics are not recommended due to their ability to cause rebound congestion. BNF 12.3.1 Drugs for oral ulceration and inflammation Benzydamine Carmellose Hydrocortisone Triamcinolone (Adcortyl in Orabase®) Choline salicylate Notes: 1. Benzydamine is useful to treat discomfort in a variety of ulcerative conditions. It may
cause stinging, often reduced by dilution with an equal volume of water.
First line drugs Second line drugs Specialist drugs Hospital only drugs
2. Care should be taken using choline salicylate gel as it may itself cause ulceration
3. All preparations for oral ulceration and inflammation are available over the counter. 4. Lidocaine ointment 5% has not been included because alternatives are included. BNF 12.3.2 Oropharyngeal anti-infective drugs Nystatin Miconazole Amphoteracin Not PAJF Notes:
1. Caution: Miconazole and other anti-fungals enhance the anti-coagulation effect of
Oral thrush is often over-diagnosed in the immunocompetent.
Prescribing is only recommended where symptomatic thrush has been identified. Oral thrush tends to be more problematic in patients with cancer, other immunocompromised patients and those on corticosteroids.
3. Failure to respond to treatment (particularly in the immunocompromised) may
indicate mouth ulceration due to herpes. The appropriate swab is required.
4. Nystatin ointment has not been included because suitable alternatives are included. BNF 12.3.4 Mouthwashes, gargles and dentifrices Chlorhexidine gluconate Mouthwash solution Hydrogen peroxide Sodium chloride Notes: 1. Chlorhexidine gluconate may be used as an antiseptic to prevent secondary
infection in mouth ulcers or following oral surgery. It can also prevent the formation of plaque.
2. Chlorhexidine gluconate is available over the counter at a cost currently under the prescription charge.
3. Hydrogen peroxide has a mechanical cleansing action particularly useful to release
4. Hydrogen peroxide is available over the counter at a cost currently under the prescription charge.
simple sodium chloride mouthwash may be made by adding one to two
teaspoonfuls of salt to a pint of freshly boiled and cooled water.
6. Sodium chloride mouthwashes may be used to relieve pain from traumatic First line drugs Second line drugs Specialist drugs Hospital only drugs BNF 12.3.5 Treatment of Dry Mouth Artificial Saliva (Luborant®) Oral spray not SDJF Artificial saliva
Glandosane® aerosol spray
not SDJF Substitutes
Biotene Oralbalance® saliva ACBS prescribe as: Note: Glandosane® and Biotene Oralbalance® should be prescribed within ACBS
guidelines to treat dry mouth as a result of receiving (or having undergone) radiotherapy or sicca syndrome. Endorse the prescription with “ACBS”. 18.13 Skin BNF 13.4 Topical corticosteroids Hydrocortisone Hydrocortisone and Miconazole Note: Hydrocortisone and miconazole cream/ointment should be prescribed in a pack size of 30g. A 15g size is available over the counter as Daktacort HC® but is more expensive than the 30g size if prescribed. BNF 13.10.1 Antibacterial preparations Sodium fusidate BNF 13.10.3 Anitviral preparations Aciclovir
1. Aciclovir cream is licensed for the treatment of herpes simplex and varicella-zoster
infections. Treatment should begin as soon as possible when the patient is symptomatic (pro-dromal phase) i.e. tingling, but once there is any evidence of a lesion, evidence shows that aciclovir is only as effective as a base cream.
2. Penciclovir is not included in the Joint Formularies. Aciclovir has a wider licensed use,
applied less frequently and is less expensive.
First line drugs Second line drugs Specialist drugs Hospital only drugs Appendix 1 Children’s doses for commonly prescribed medications The following are recommended doses for healthy, full-term infants and children. Please refer to product literature / BNF for Children for further advice. Ref: BNF for Children 2005 Drug Presentation 12-18yrs Analgesics Ibuprofen 1-2 yrs: 50mg 3-4 times 2-7 yrs: 100mg 3-4 times Maximum: 2.4g/day 7-12 yrs: 200mg 3-4 times Paracetamol 1-5yrs: 120-250mg 4-6hrly 6-12yrs: 250-500mg 4-6hrly Maximum 4 doses in 24 hours Maximum daily dose: >3months: 90mg/kg/day Adults: 4g / day Antibiotics Amoxicillin 1-5 yrs: 125mg TDS 5-12 yrs: 250mg TDS Cefalexin 1-5 yrs: 125mg TDS 5-12 yrs: 250mg TDS Erythromycin 1-2 yrs: 125mg QDS ethyl succinate 2-8 yrs: 250mg QDS 8-12 yrs: 250-500mg QDS Metronidazole Phenoxymethyl- 1-6 years: 125mg QDS penicillin 6-12 years: 250mg QDS First line drugs Second line drugs Specialist drugs Hospital only drugs Appendix 2 Prevention of endocarditis in patients with heart- valve lesion, septal defect, patent ductus, prosthetic valve, or history of endocarditis Reference: BNF55- March 2008 NICE Clinical Guideline 64 (March 2008) Note: This appendix previously contained guidance on the use of prophylactic antibiotics to prevent incidences of endocarditis in at risk patients undergoing dental surgery, in accordance with the recommendations of a Working Party of the British Society for Antimicrobial Chemotherapy. However, these recommendations have changed following a review by NICE (CG 64) in association with the British Society for Antimicrobial Chemotherapy which found no clear association between dental procedures and the development of infective endocarditis. Furthermore, there is no evidence of benefit from the use of prophylactic antibiotics. As a result, patients who were previously prescribed prophylactic antibiotics prior to dental surgeryno longer need to take them.
Further information on the published NICE guidance, including information for patients, carers and members of the public who may be concerned by the change in recommendations, is available on the NICE website at:
NICE Clinical Guideline 64 (March 2008) Antibiotic prophylaxis against infective endocarditis in adults and children undergoing interventional procedures
Antibacterial prophylaxis and chlorhexidine mouthwash are not recommended for the prevention of endocarditis in patients undergoing dental procedures.
Antibacterial prophylaxis is not recommended for the prevention of endocarditis in patients undergoing procedures of the:
upper and lower respiratory tract (including ear, nose, and throat procedures and bronchoscopy);
genito-urinary tract (including urological, gynaecological, and obstetric procedures);
upper and lower gastro-intestinal tract.
Whilst these procedures can cause bacteraemia, there is no clear association with the development of infective endocarditis. Prophylaxis may expose patients to the adverse effects of antimicrobials when the evidence of benefit has not been proven.
Any infection in patients at risk of endocarditis should be investigated promptly and treated appropriately to reduce the risk of endocarditis.
If patients at risk of endocarditis are undergoing a gastro-intestinal or genito-urinary tract procedure at a site where infection is suspected, they should receive appropriate antibacterial therapy that includes cover against organisms that cause endocarditis.
Patients at risk of endocarditis should be:
told how to recognise signs of infective endocarditis, and advised when to seek expert advice.
Joint prostheses and dental treatment Advice of a Working Party of the British Society for Antimicrobial Chemotherapy is that First line drugs Second line drugs Specialist drugs Hospital only drugs
patients with prosthetic joint implants (including total hip replacements) do not require antibiotic prophylaxis for dental treatment. The Working Party considers that it is unacceptable to expose patients to the adverse effects of antibiotics when there is no evidence that such prophylaxis is of any benefit, but that those who develop any intercurrent infection require prompt treatment with antibiotics to which the infecting organisms are sensitive. The Working Party has commented that joint infections have rarely been shown to follow dental procedures and are even more rarely caused by oral streptococci.
First line drugs Second line drugs Specialist drugs Hospital only drugs
*Most Brand Name drugs with generic alternatives are designated ascefaclor, cefadroxil, cephadrine, cephalexinNon-Preferred drugs. Below is a list of commonly prescribed Brand Name drugsthat have generic alternatives. Please note that this list is not all inclusive. 2 0 0 3 N O N - P R E F E R R E D a n d P R E F E R R E D D R U G L I S TThis preferred drug list has been reviewed by physician
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