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Microsoft word - 18_chp18_2009_book version_formatted.doc

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 5.1.1.1 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 5.1.1.1 Benzylpenicillin and phenoxymethylpenicillin
Phenoxymethylpenicillin

BNF 5.1.1.3 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: Amphoteracin not PAJF, miconazole and nystatin are included in section 12.3.2.
BNF 5.3.2 Herpesvirus infections
Aciclovir

Š Tablets 200mg
Š (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®) Š Oral spray
not SDJF
Artificial saliva

Š Glandosane® aerosol spray
Š not SDJF
Substitutes
Š 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 surgery
no 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: http://www.nice.org.uk/guidance/index.jsp?action=byID&o=11938 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

Source: http://dentiststudybuddy.org.uk/wp-content/uploads/2012/09/DENTAL-PRESCRIBING.pdf

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