Antibiotics and Antimicrobials
Amoxicillin 50 mg/ml (Amoxil ® , Trimox ® , Wymox ® ) [Child] Dsp: 200 ml
Sig: Take 1 hour before dental procedure.
Use: For penicillinase-resistant infection.
Note: 50 mg/kg; total children’s dose should not exceed adult dose.
Sig: Take 1 tablet every 6 hours for 10 days.
Use: For penicillinase-resistant infection.
Caution: Decrease the dosage by 25–50% in the renal compromised patients Affects the potency of oral contraceptives.
Amoxicillin 500 mg/clavulanate 125 mg (Augmentin ® ) Dsp: #30
Sig: Take 1 tablet every 8 hours for 10 days.
Use: For penicllinase-resistant infection (inhibits beta- lactamases).
Note: Take with food/milk to decrease GI effects.
Caution: Decrease the dosage and/or frequency of administration in renal-compromised patients.
Azithromycin 250 mg, 500 mg, 600 mg (Zithromax ® ; Zmax ® )
Sig: Take 2 capsules on day 1 at bedtime, then 1 capsule every day for the next 4 days.
Use: For mild to moderate infections of the upper respiratory tract, lower respiratory tract, uncomplicated skin, and skin structure infections caused by
H infl uenzae, Clostridium, and L pneumophila Alternate drug for penicillin-allergic patients.
Note: Extended spectrum of activity Antacids decrease the absorption Safe to use during pregnancy and end- stage renal disease Generic formulations are available
Zmax is a single-dose enhancement (extended release) of Z-pak (six 250-mg tablets taken over 5 days).
Caution: Decreases action of clindamycin, penicillins, lincomycin, oral contraceptives Contraindicated in liver disease May potentiate the effects of oral anticoagulants.
Sig: Take 1 capsule every 8 hours.
Use: Bactericidal; soft tissue infection of susceptible microorganism.
Caution: May cause a false-positive clinitest; renal or hepatic dysfunction; GI disease, especially colitis.
Cefaclor 125 mg/5 ml suspension (Ceclor ® ) [Child] Dsp: 150 ml
Sig: For greater than 1 month: 20–40 mg/kg/day divided every 8–12 hours; maximum dose is 2 g/day.
Use: Bactericidal; soft tissue infection of susceptible microorganism.
Note: Twice-daily option is for treatment of otitis media and pharyngitis.
Caution: May cause a false-positive clinitest; renal or hepatic dysfunction; GI disease, especially colitis.
Sig: Take 1 tablet twice daily for 10 days.
Use: Bactericidal; mild to moderate pharyngitis/tonsillitis in adults and adolescents caused by S pyogenes. Note: Not recommended when long antibiotic treatment is necessary.
Caution is advised when administering this medication to patients with carnitine deficiency, and dosage adjustments are essential for those with moderate to severe renal insufficiency Additionally, pharmacokinetics have not been evaluated in individuals with severe hepatic impairment, nor for preventing rheumatic fever after S pyogenes pharyngitis or tonsillitis.
Warning: If given to penicillin-sensitive patients, caution should be exercised because cross-hypersensitivity among beta-lactam antibiotics has been clearly documented.
Cephalexin monohydrate 250 or 500 mg (Kefl ex ® ) Dsp: #40
Sig: Take 1 capsule every 6 hours for 7 days.
Use: Bactericidal; possible drug of choice when penicillin is ineffective in 48 hours for g (+) infections; often ineffective for penicillinase-secreting organisms; seems
3 to have less cross-allergenicity than other cephalosporins (e.g., cephalothin sodium, cephadrine, cefoxitin).
Caution: Do not give more than 4 g/day Decrease the dosage in renal-compromised patients.
Cephalexin monohydrate 125 mg/5 ml suspension
Sig: 25–50 mg/kg/day every 6 hours; severe infections: 50–100 mg/kg/day in divided doses every 6 hours; maximum: 3 g/24 hours.
This bactericidal agent may be the preferred option when penicillin fails to show effectiveness within 48 hours for Gram-positive infections However, it is often ineffective against organisms that secrete penicillinase Notably, this drug appears to exhibit lower cross-allergenicity compared to other cephalosporins, such as cephalothin sodium, cephadrine, and cefoxitin.
0.12% chlorhexidine gluconate (Peridex ® ; PerioGard ® , generics)
Sig: Swish 1 tsp for 1 minute then expectorate; perform twice daily morning and evening after tooth brushing Avoid eating or drinking for 30 minutes.
Use: reduces the pathogenic microbial fl ora associated with infl ammatory signs of oral disease.
Caution: May stain teeth yellow to brown; alter taste temporarily; increase the deposition of calculus Contains 11.6% alcohol.
0.12% chlorhexidine gluconate oral rinse without alcohol (CHX ® )
Sig: Swish 15 ml for 1 minute then expectorate; twice daily morning and evening after tooth brushing and meals Avoid eating or drinking for 30 minutes.
Use: Reduces the pathogenic microbial fl ora associated with infl ammatory signs of oral disease.
Caution: May stain teeth yellow to brown; alter taste temporarily; increase the deposition of calculus.
0.2% aqueous chlorhexidine gluconate (compounded by pharmacist; only ask for peppermint, raspberry, or spearmint fl avoring agents).
Sig: Swish 1 tsp for 1 minute then expectorate; perform twice daily morning and evening after tooth brushing Avoid eating or drinking for 30 minutes.
Use: Reduces the pathogenic microbial fl ora associated with infl ammatory signs of oral disease.
For individuals with alcoholism and those suffering from xerostomia, such as post-irradiation patients, a non-alcohol formulation is essential This product is exclusively available through specialty-compounding pharmacists To locate a participating pharmacist near you, please call 1-800-331-2498 The formulation has a shelf life of six months.
Caution: may stain teeth yellow to brown; alter taste temporarily; increase the deposition of calculus.
Sig: Take 1 tablet 2 times a day for 7 days.
Use: Complex periodontal infections (very effective against staph infections).
Note: It can be used in combination with metronidazole (i.e., 500 mg of ciprofl oxacin twice daily for 7 days with
250 mg of metronidazole 250 4 times daily for 7 days Antacids decrease absorption; cimetidine increases levels.
Caution: Can cause CNS stimulation Causes cyclosporine and theophylline toxicity Do not administer with dairy foods.
Contraindicated in patients receiving tizanidine (Zanafl ex ® ).
Sig: Take 2 tablets per day for 7 days.
Use: For mild to moderate infections of the upper respiratory tract and maxillary sinusitis Active against gram-negative anaerobes in addition to bacteria that erythromycin is effective against.
Note: Can be taken with food and dairy products.
Caution is advised as this substance may reduce the effectiveness of anticholinergic drugs while enhancing the effects of cyclosporine and warfarin Additionally, it can diminish the action of clindamycin, penicillins, lincomycin, oral contraceptives, rifabutin, rifampin, and zidovudine It is contraindicated for use with terfenadine and astemizole.
5 cisapride Avoid in pregnancy and hepatic or renal disease.
Clindamycin 150 mg or 300 mg (Cleosin HCl ® ) Dsp: #60
Sig: Take 1 capsule every 6 hours for 7 days.
This antibiotic is primarily bacteriostatic and may exhibit bactericidal properties, showing the highest efficacy against Bacteroides infections, various other anaerobes, and staphylococci, while being ineffective against enterococci In cases of mild to moderate renal or hepatic disease, dosage adjustments are unnecessary; however, a 50% reduction is required for patients with end-stage renal disease or cirrhosis.
Caution: May cause clostridia pseudomembranous ulcerative colitis 2–9 days after the start of therapy; discontinue immediately.
Clindamycin 75 mg/5 ml (Cleosin Pediatric ® ) [Child] Dsp: 100 ml
Sig: Take in 3–4 equally divided doses.
Use: Bacteriostatic, may be bactericidal; most effective against Bacteroides infections, most other anaerobes, staphylococci; not effective against enterococci. Note: 8–25 mg/kg
Caution: May cause clostridia pseudomembranous ulcerative colitis.
Dicloxacillin 250 mg (also 500 mg) (Dynapen ® , Dycill ® ) Dsp: #40
Sig: Take 1 tablet every 4 hours for 5–7 days.
This bactericidal agent is the preferred alternative when penicillin fails to show effectiveness within 48 hours It is particularly effective against staphylococci that are resistant to penicillin G and those that secrete penicillinase Additionally, it achieves significantly higher blood levels compared to methicillin, making it a robust choice in treating resistant bacterial infections.
Note: Should be taken on an empty stomach.
Caution: Use with caution in renal-compromised patients
(decrease the dose); increases the effectiveness of anticoagulants.
Sig: Take 1 tablet at bedtime on fi rst day, then 100 mg/ day at bedtime for 7–10 days (usually 10 days).
Periodontal disease can be treated with tetracycline HCl, which is safe for patients with renal disease without requiring dose adjustments However, it is important to note that tetracycline HCl can enhance the effects of coumadin and may lead to digoxin toxicity This medication can be administered with food for better tolerance.
Caution is advised when using this medication in children under 8 years old, pregnant patients, and individuals with severe liver disease For patients with severe liver impairment, it is recommended to reduce the dosage by 50% However, those with mild to moderate liver disease may use the medication without any dosage adjustments It is important to avoid administering this medication to patients who have both liver and kidney disease.
Doxycycline hyclate 10.0% (Atridox ® ); in the ATRIGEL ® delivery system
Sig: 1 pouch containing a doxycycline hyclate syringe
The final blended product consists of 500 mg of formulation containing 50 mg of doxycycline hyclate, delivered via an ATRIGEL Delivery System syringe (450 mg) and a blunt cannula This treatment is specifically designed for chronic adult periodontitis, aiming to enhance clinical attachment, decrease probing depth, and minimize bleeding upon probing.
For optimal results, take one capsule twice daily, ensuring at least one hour before meals, as a supplementary treatment after scaling and root planing for a duration of up to nine months It is also advisable to consume a sufficient amount of fluids while taking the capsules.
Use: Adjunct to scaling and root planing to promote attachment level gain and to reduce pocket depth in patients with adult periodontitis.
Caution: Safety beyond 12 months and effi cacy beyond
9 months have not been established.
Erythromycin ethylsuccinate 400 mg (EES ® , ERYC ® , Ery-Tab ® )
Sig: Take 1 tablet 3 times a day Continue for 7 days. Use: Bactericidal; upper and lower respiratory tract acute infections, soft tissue infections.
Note: Inhibits cytochrome P-450 enzyme in the liver, thus decreasing the clearance of theophylline, cyclosporine, and carbamazepine.
Caution: Avoid in patients with liver disease Causes digoxin and theophylline toxicity.
Sig: Prescribe 30–50 mg/kg/day divided every 6–8 hours; do not exceed 2 g/day.
Use: Bactericidal; upper and lower respiratory tract acute infections, soft tissue infections.
Erythromycin stearate 500 mg (Erythromycin ® ) or
Sig: Take 1 tablet every 6 hours for 10 days.
Use: Bacteriostatic; odontogenic infections in patients allergic to penicillin (second choice for oral abscesses), active against gram (+) cocci, may be useful against
Haemophilus spp and Mycoplasma spp.; Legionnaire’s disease; also available IM, IV.
Sig: Take 2 tablets immediately, then 1 tablet every
Use: Anaerobic soft tissue infections caused by anaerobic cocci, bacteroides, and clostridium; for febrile patient with acute necrotizing ulcerative gingivitis involving anaerobic bacteria.
Note: Useful as a single agent or in combination with amoxicllin, Augmentin ® , or ciprofl oxacin in the treatment of periodontitis associated with the presence of Actinobacillus actinomycetem- comitans.
Caution: Avoid alcohol and do not use in patients with liver or kidney disease.
Minocycline 4 mg bioresorbable powder in a disposable cartridge (Arestin ® )
Sig: Insert 1 unit-dose cartridge in supplied handle and then place in each periodontal diseased pocket (variable dose depending on size, shape, and number of pockets being treated).
Use: An adjunct to scaling and root planing procedures for the reduction of pocket depth in patients with adult periodontitis.
After periodontal scaling and root planing, the cartridge is positioned at the base of the pocket The thumb ring on the handle mechanism is then pressed to release the powder while slowly withdrawing the tip from the pocket's base It is essential to sterilize the handle between uses to maintain hygiene.
Patients are advised to refrain from consuming hard, crunchy, or sticky foods for one week following treatment Additionally, they should delay brushing for 12 hours and avoid touching the treated areas The use of interproximal cleaning devices should be postponed for 10 days after administration This treatment is not recommended for use in acutely abscessed periodontal pockets.
Caution is advised when using tetracycline-class drugs during tooth development, as they can lead to lasting tooth discoloration Additionally, some individuals may experience heightened photosensitivity, resulting in severe sunburn reactions.
Sig: Take 1 tablet every 6 hours.
Use: Bactericidal; active against g (+) cocci aerobic and anaerobic, not beta-lactamase–producing staphylococci; most anaerobes except Bacteroides fragilis are susceptible; also available IV.
Penicillin V potassium 250 or 500 mg (Veetids ® ) Dsp: #28
Sig: Take 1 tablet 4 times a day for 5–7 days.
Use: Oral bacterial and viral infections.
The most effective antibiotic for treating most oral infections is effective against a variety of bacteria, including Strep viridans, group A strep, anaerobic strep, Bacteroides, gram-negative rods, and many staphylococci, although it may not be effective against all strains.
Caution: Avoid in renal compromised patients; no longer recommended for dental procedure prophylaxis.
Penicillin V potassium liquid 125 mg/5 ml (Pen-Vee K ® liquid) [Child]
Sig: Take 1 tsp every 6 hours.
Use: Bactericidal; odontogenic infections (e.g., abscess, cellulitis), ANUG with fever, oral gonorrhea Same as penicillin G although less active against anaerobes than penicillin G.
Sig: Take 2 tablets immediately and then 1 tablet every
Use: Bactericidal; odontogenic infections (e.g., abscess, cellulitis), ANUG with fever, oral gonorrhea Same as penicillin G although less active against anaerobes than penicillin G.
Sig: Take 1 tablet or capsule every 6 hours Continue for
Use: Bacteriostatic; active against many anaerobes and enteric gram negative rods Fair activity against Strep viridans.
Tetracycline HCl oral suspension 250 mg/tsp
Sig: Take 1 teaspoon 4 times a day, rinse orally 5 minutes and swallow.
Use: Minor, major, and herpetiform aphthous stomatitis; active against certain g (+) cocci; Bacteroides fragilis commonly resistant but not Actinobacillus spp or
Capnocytophaga can be administered via intramuscular (IM) or intravenous (IV) routes Caution is advised when using Doxycycline hydrate (Vibramycin) in cases of renal impairment or tooth staining, particularly for pregnant individuals and children under 8 years old, as dairy and antacid products may inactivate the medication.
Sig: Dissolve 1 tablet in 1 tsp of warm water, then swish solution for 3–5 minutes and swallow Repeat 4 times daily.
Use: Reduces the pathogenic microbial fl ora associated with infl ammatory signs of oral disease.
Dsp: 1 box of 10 fi bers
Sig: Insert fi ber into periodontal pocket up to gingival margin while maintaining contact with pocket base Secure with cyanoacrylate adhesive.
Use: Adjunct to scaling and root planing in patients with active periodontitis.
Note: Fibers lost during fi rst 7 days must be replaced.
Caution: May reduce the effectiveness of oral contraceptives; may permanently stain teeth; not for use with acute abscesses; remove after 10 days or immediately if erythema occurs.
Trimethoprim 80 mg and sulfamethoxazole 400 mg
Sig: Take 1 tablet every 12 hours.
Use: For infections involving Escherichia coli, Hemophilus infl uenzae, Klebsiella, and Enterobacter spp.
Note: Usually not used for dental infections.
Sig: Take 1 tablet 4 times a day for 1 week.
Use: Pseudomembranous colitis produced by C diffi cile; infections for suspected or documented methicillin- resistant Staph aureus or beta-lactam–resistant coagulase-negative Staphylococcus.
Note: Can be given during hemodialysis, at the dialysis site, for SBE prophylaxis Stays effective for 7 days, post- dialysis.
Caution: Contraindicated in patients with kidney disease.
Sig: Rinse with 1 / 2 oz twice daily for 30 seconds and expectorate Avoid rinsing or eating for 30 minutes following treatment.
Use: Antiplaque and gingivitis agent; relapse prevention tool for post-chlorhexidine treatment and at-home maintenance therapy after scaling and root planing.Note: Proprietary 0.2% delmopinol hydrochloride; not
11 bactericidal but, rather, disrupts the development and maturation of biofi lm
Sig: Rinse 1 tsp in the mouth for 1 minute and spit out, twice daily.
Use: For acute necrotizing ulcerative gingivitis.
Note: Should be used for a maximum of only 2 days.
Caution: Not to be used in patients allergic to iodine
Solution should be completely spit out.
Sig: Rinse 1 tbsp in mouth for 30 seconds, twice daily. Use: Antiplaque and gingivitis agent.
Note: ADA seal of approval.
Sig: Brush teeth with toothpaste 2–3 times a day. Use: Antiplaque and gingivitis agent.
Note: ADA seal of approval.
OVER-THE-COUNTER REMOVABLE PROSTHESES
1 Removal of debris and concretions by dishwashing liquid detergent or white vinegar Ultrasonic cleaners may be used, but there are anecdotal reports of tooth and clasp dislodgment.
2 Soak in full-strength household chlorine bleach (0.525% sodium hypochlorite) for 10 minutes (set timer), then rinse thoroughly in cool water Repeat weekly.
Note: May adversely affect dental alloys, acrylics, and tissue-conditioning material If the metal does not darken or dull the surface, then it is okay to use.
Tufts University School of Dental Medicine:
1 Remove dentures from mouth and clean with a brush at least two times a day This should be done over a sink fi lled with water.
2 Once per week, soak denture overnight in a cleansing solution to remove stains and other accumulations Recommended solution is:
3 Rinse well with water before inserting denture back into mouth
Warning: Do not place denture with metal into this solution Use vinegar and water instead OR
If metal affected, then try:
Antihistamines and Palliative Coating
Diphenhydramine HCl 50 mg (Benadryl ® ) or promethazine 12.5 mg (Phenergan ® ; generic available)
Sig: Take 1 tablet 3 times daily for 2–3 days.
Use: Mild to moderate allergic stomatitis of the immediate type, erythema multiforme.
When using diphenhydramine, it is crucial to limit the dosage to no more than 50 mg per visit This medication should not be administered during acute asthma attacks and is contraindicated for individuals with a history of hyperthyroidism or angle-closure glaucoma Additionally, diphenhydramine should be avoided in conjunction with alcohol, barbiturates, opioids, MAO inhibitors, or any other centrally acting drugs.
Diphenhydramine elixir 12.5 mg/5 ml (Benadryl ® ) or promethazine syrup 6.25 mg/5 ml (Phenergan ® ) with
Kaopectate (attapulgite) or Milk of Magnesia 4 oz [Child and Adult]
Dsp: 8 oz.; compound the ingredients
Rinse with 1 teaspoon every two hours and expectorate for effective relief This treatment is indicated for immediate-type allergic stomatitis and erythema multiforme, providing palliative care for painful vesiculoulcerative lesions like primary herpetic gingivostomatitis, while also offering sedation and antiemetic effects.
Dyclonine HCl 0.5% (1 oz) can enhance anesthetic efficacy, while sucralfate (Carafate®) 1 g/10 ml or Maalox (aluminum hydroxide, magnesium hydroxide) may serve as alternatives to Kaopectate or Milk of Magnesia It is important to note that the palliative rinse offers no therapeutic effect, and allergic reactions are very rare.
When using topical anesthetics, patients should be aware of a diminished gag reflex, necessitating caution during eating and drinking to prevent airway issues Additionally, these preparations may lead to constipation and drowsiness; if constipation occurs, Maalox® can be used as an alternative to Kaopectate or Milk of Magnesia.
Benacort-tetrastat elixir (Mary’s magic potion ® ) Dsp: 1.5 g tetracycline, 60 mg hydrocortisone, 6 million international units nystatin, 240 ml q.s elixir of Benadryl Sig: Rinse with 1 tsp 4 times daily for 2 minutes and expectorate
Use: Severe mucositis; sedation effects.
Caution: In xerostomic patients, it increases likelihood of caries.
Dsp: 80 ml oral 2% viscous lidocaine, 80 ml Maalox (aluminum hydroxide, magnesium hydroxide), 80 mg hydrocortisone, 160 ml distilled water
Sig: Rinse with 1 tsp 4 times daily for 2 minutes and expectorate.
Dsp: 40 ml Dimetapp elixir, 80 ml Kaopectate
Sig: Shake well and rinse with 1 tsp as needed for 2 minutes and expectorate.
Topical Anesthetics, Chemical Cauterizers,
20% benzocaine gel or liquid or spray (Hurricaine ® ) Dsp: 1 oz.
Sig: Apply small amount to ulcer as needed for pain. Use: Palliation of painful vesiculoulcerative lesions.
In 2011, the FDA warned that over-the-counter benzocaine gels and liquids, when applied to the gums or other areas of the mouth, can lead to a rare but serious condition called methemoglobinemia Due to safety concerns, benzocaine products are not recommended for children under 2 years old, such as for teething, unless prescribed and monitored by a healthcare professional.
14% benzocaine with 2% butamben 2% tetracaine gel or liquid or ointment (Cetacaine ® )
Dsp: 56 g (liquid) or 29 g (gel) or 37 g (ointment) Sig: Apply small amount to ulcer as needed for pain. Use: Palliation of painful vesiculoulcerative lesions.
In 2011, the FDA warned that over-the-counter benzocaine gels and liquids used on the gums or other mouth areas can lead to a rare but serious condition called methemoglobinemia It is crucial to avoid using benzocaine products on children under 2 years old, such as for teething, unless directed by a healthcare professional.
Sig: Rinse with 1 tsp for 2 minutes before each meal and expectorate.
Use: Palliation of painful vesiculoulcerative lesions. Note: If you cannot fi nd Dyclone ® , have the pharmacist compound it and place it in a mechanical spray pump
To fi nd the nearest pharmacist who participates in the Compounding Centers of America, call 1-800-331-2498.
Sig: Apply 3 drops with clean fi ngertip or cotton-tipped applicator to oral sores as needed for pain, then expectorate; alternatively, 2 tsp may be rinsed in the
15 mouth and then expectorate For infant or toddler, apply 3 drops to pacifi er (see Caution).
Use: Palliation of painful vesiculoulcerative lesions. Note: This preparation can be used for infants who are unable to rinse.
Parents should closely monitor their child after administering anesthetic, as swallowing can trigger a gag reflex There have been reports of serious side effects, including arrhythmias and seizures, due to excessive use of the anesthetic.
Sig: Swish with 1 tbsp before each meal and expectorate. Use: Palliation of painful vesiculoulcerative lesions.
Sig: Apply small amount to ulcer as needed for pain. Use: Palliation of painful vesiculoulcerative lesions.
Sig: Spray for 2 seconds on ulcer as needed for pain. Use: Palliation of painful vesiculoulcerative lesions.
Sig: Apply to affected area before meals and as needed for pain.
Use: Palliation of painful vesiculoulcerative lesions (e.g., aphthous ulcer).
In 2011, the FDA warned that over-the-counter benzocaine gels and liquids used on the gums or other oral areas can lead to a rare but serious condition known as methemoglobinemia It is crucial to avoid using benzocaine products in children under the age of 2, such as for teething, unless directed and monitored by a healthcare professional.
Debacterol ® single-use applicator package (30% sulfuric acid and 22% sulfonated phenolics); 1 box (24
16 individually wrapped applicator sets consisting of a prefi lled [0.2 ml] cotton swab applicator and drying cotton swab) Dsp: 1 applicator package
To effectively use Debacterol, first dry the affected area with a drying swab Hold the applicator upright with the colored ring facing up, then gently bend the ring to one side until it snaps to initiate the flow of Debacterol Apply the solution directly to the affected area for a maximum of 5 seconds, then rinse thoroughly with water and expectorate Finally, dispose of the used applicator properly.
For immediate relief from painful minor aphthous ulcers, use a topical treatment If you experience excessive irritation, rinse your mouth with a solution of 0.5 teaspoons of sodium bicarbonate in 120 ml of water to neutralize the reaction.
Polyphenolsufonic acid complex, 100 ml, formaldehyde solution, 18 ml, distilled water, 42 ml [Negatan ® ] Dsp: Compound the ingredients
Sig: Dry ulcer and then apply 1 drop for 15 seconds and then rinse with water.
Use: Palliation of painful vesiculoulcerative lesions (e.g., aphthous ulcer).
Note: Negatan ® is no longer available in the United States Have the pharmacist compound it Call
1-800-331-2498 to fi nd the nearest pharmacist who participates in the Compounding Centers of America.
Sig: Dry ulcer thoroughly, then apply topical anesthetic; lightly apply the silver nitrate on an applicator to the ulcer base for 5 seconds, then rinse with water.
Use: Palliation of painful minor aphthous ulcer.
Caution: The clinician must use extreme care not to burn adjacent uninvolved mucosa by drying the area thoroughly before applying the cauterizing agent.
10% podophyllum resin (Podofi n ® ) and benzoin tincture compound solution
Sig: Dry the mucosal surface and apply 1 drop at a time allowing drying between drops Apply until area is
17 covered but do not apply more than a volume of 0.5 ml at each treatment session.
Use: Viral conditions such as condyloma acuminatum Off-label use for excess keratinization of mucosal surfaces such as hairy tongue.
Caution: A 25% solution may be used on skin but limit to
10% solution on or near mucosal surfaces.
Antifungals
Amphotericin B oral suspension 100 mg/ml
Sig: Swish 1 ml 4 times a day in the mouth (after meals and at bedtime) for 3–4 minutes and swallow Do not eat or drink for 30 minutes after use.
Use: Mucocutaneous and oropharyngeal candidiasis when topical therapy is ineffective.
Note: Fungizone ® product is no longer available.
Amphotericin B oral suspension 100 mg/ml
Sig: Swab 1 ml 4 times a day in the mouth (after meals and at bedtime) for 3-4 minutes and swallow Do not eat or drink for 30 minutes after use.
Use: Mucocutaneous and oropharyngeal candidiasis when topical therapy is ineffective and the patient is debilitated and cannot rinse.
Note: Fungizone trade name product is no longer available Can dilute to 100 mg/4 ml for easy swish and expectorate.
Sig: Apply to affected areas 2–4 times/day for 1–4 weeks of therapy depending on the nature and severity of the infection.
Use: Mucocutaneous and cutaneous Candida infections.
Dsp: Injection, powder for reconstitution
For the treatment of candidemia, intra-abdominal, or peritoneal infections in adults, a 200 mg loading dose is administered on day 1, followed by a daily dose of 100 mg for a minimum of 14 days after the last positive culture In cases of esophageal candidiasis, a 100 mg loading dose is given on day 1.
18 followed by 50 mg daily for at least 7 days after symptom resolution.
Use: Esophageal candidiasis, candidemia, abdominal abscesses and peritonitis with Candida (echinocandin)
Caspofungin acetate is available in 50 mg and 70 mg formulations (Cancidas®) and is administered as an injectable powder for reconstitution For esophageal candidiasis, the recommended dosage is 50 mg per day, infused slowly over one hour In cases of invasive aspergillosis, the initial dose is 70 mg on the first day, followed by a maintenance dose of 50 mg per day.
Use: Invasive aspergillus infections in patients who are refractory or intolerant of other therapy; candidemia and other Candida infections (intra-abdominal abscesses, esophageal, peritonitis, pleural space).
Warning: Concurrent use of cyclosporine should be limited to patients for whom benefi t outweighs risk owing to a high frequency of hepatic transaminase elevations
Sig: Dissolve, in mouth, 1 troche as a lozenge 5 times daily for 14 consecutive days.
After using the troche, it is important to remove any dentures and avoid eating or drinking for 30 minutes The troche contains sucrose, which may increase the risk of dental caries with prolonged use exceeding three months, so caution is advised, especially for diabetic patients.
Clotrimazole 1% cream (Lotrimin-Rx ® , generic) Dsp: 15 g
Sig: Apply thin fi lm to inner surface of denture and/or angles of mouth 4r times a day (after each meal and at bedtime).
Use: Denture sore mouth; angular cheilitis.
After using the treatment, refrain from eating or drinking for 30 minutes It's important to continue the treatment for at least three days after symptoms have visibly improved For an affordable alternative, an over-the-counter athlete’s foot cream like Lotrimin AF can be used in the same manner.
Sig: Apply a thin amount to the affected area twice daily.Use: Angular cheilitis.
Clotrimazole 10 mg/ml suspension [Infant or Child]
Dsp: 90 ml; the pharmacist should blend 900 mg of clotrimazole powder into to 2 tubes of Oral Balance moisturizing oral gel.
Sig: Swab 1–2 ml on affected area 4 times a day (after meals and at bedtime).
Use: Fungicidal; oral candidiasis in debilitated patients who cannot rinse and for very young children when a rinse is ineffective.
Note: Shake before using; do not eat or drink for 30 minutes following use To fi nd your nearest pharmacist who participates in the Compounding Centers of America, call 1-800-331-2498.
Fluconazole 100 mg tablets (Difl ucan ® ); also available in 50 mg, 150 mg and 200 mg tablets
To effectively treat oral candidiasis, take 2 tablets on the first day, followed by 1 tablet daily for 14 days; for esophageal candidiasis, continue for 21 days For systemic candidiasis, start with 4 tablets on the first day, then take 2 tablets daily for 28 days This medication is indicated for systemic fungal infections, including oropharyngeal, esophageal, mucocutaneous, and systemic candidiasis, particularly in HIV-seropositive patients.
Caution: Avoid in patients with severe liver and kidney disease.
Fluconazole 100 mg tablets (Difl ucan ® )/hydrocortisone
10 mg and iodoquinol 10 mg (Alcortin A gel ® )
For effective treatment, apply a thin layer of cream to the affected area 3 to 4 times daily for 10 days Additionally, start with a dose of 200 mg of fluconazole on day 1, followed by 100 mg daily from days 2 to 10.
Use: Severe exfoliative cheilitis (chapped lips).
Note: Patient must stop lip licking habit for complete resolution.
Flucytosine 250 mg or 500 mg (Ancobon ® )
Sig: Take 50–150 mg/kg/day in divided doses every
Use: Adjunctive treatment of susceptible fungal infection; used in combination with amphotericin B, fl uconazole, or
20 itraconazole Synergistic with amphotericin B for fungal infections (Aspergillus spp.).
Hydrocortisone 10 mg and iodoquinol 10 mg (Alcortin
Sig: Apply small dab to corner of mouth, 4 times a day. Use: Angular cheilitis; candidiasis.
Note: Advise patient to avoid contact with oral cavity because it has a very bitter taste.
Sig: Apply as a thin fi lm 3–4 times daily to the affected area.
Note: Do not use with an occlusive dressing.
Sig: Take 1 capsule twice daily or 2 tablets with a meal or orange juice.
Use: Fungistatic; oral candidiasis when topical therapy is not practical or is ineffective Also may be used for blastomycosis and histoplasmosis,
Aspergillus, Coccdioides, Cryptococcus, Sporothrix, and chromomycosis.
Note: Dose may be increased 100 mg/day to 400 mg/day Doses greater than 200 mg/day should be given in
Caution: May cause irreversible liver damage; avoid in congestive heart failure.
Itraconazole 10 mg/ml oral solution (Sporonox ® ) Dsp: 150 ml
Sig: Swish in mouth and swallow 200 mg daily for 1–2 weeks.
Use: Fungistatic; oral candidiasis when other topical therapy is ineffective Also may be used for blastomycosis and histoplasmosis, Aspergillus, Coccdioides,
Note: Dose may be increased 100 mg/day to 400 mg/day
Doses greater than 200 mg/day should be given in
Caution: May cause irreversible liver damage.
For effective treatment, gently rub the product onto the affected area 1-2 times daily It serves a fungistatic purpose, particularly for conditions like oral candidiasis and angular cheilitis Denture wearers should apply a thin film to the inner surface of their dentures and refrain from eating or drinking for 30 minutes after application.
Caution: May cause irreversible liver damage.
Ketoconazole cream 2% (Nizoral ® , generic) mixed with equal parts of triamcinolone acetonide 0.1% or 0.5% ointment (Kenalog) or fl uocinonide 0.05% ointment
(Lidex ® ) or clobetasol 0.05% ointment (Temovate ® ). Dsp: 30 g
Sig: Apply thin fi lm to inner surface of dentures or medication trays twice daily May also gently rub into the affected area once or twice daily.
Sig: Take 1 tablet daily, with a meal, for 2 weeks. Use: Fungistatic; oral and mucocutaneous candidiasis when patient cannot tolerate topical therapy or respond to topical (e.g., nystatin).
Note: Do not take antacids within 1 hour of this medication.
Caution: May cause irreversible liver damage; liver function should be monitored with long-term use (>3 weeks) Multiple severe drug interactions possible, especially with some antihistamines.
Dsp: IV adults: powder for reconstitution as sodium; contains lactose.
Sig: For esophageal candidiasis, 150 mg daily with median trial of 14 days; for prophylaxis of Candida infection in hematopoietic stem cell transplantation
50 mg daily with median trial of 18 days.
Use: Inhibits cell wall synthesis (new echinocandins class); esophageal candidiasis; prophylaxis in patients
22 undergoing hematopoietic stem cell transplant Unlabeled use for aspergillus infections and prophylaxis for HIV- related esophageal candidiasis.
Note: Side effects include isolated serious cases of serious hypersensitivity and anemia as well as changes in liver and kidney function.
Miconazole buccal 50 mg tablets (Oravig ® )
Sig: Apply 1 mucosa-adhering tablet to the gingiva daily for 2 weeks.
Use: Oropharyngeal candidiasis (especially immune- depressed patients); also may be preferred in patients suffering from salivary gland hypofunction compared with other azoles.
Note: Cost can be prohibitive for some patients; however, single dose per day enhances patient compliance.
Caution: Monitor in patients with a history of hypersensitivity to azoles.
Nystatin oral suspension 100,000 IU/ml (Mycostatin ® , Nilstat ® )
Sig: Take 1 tsp (2–5 ml) every 6 hours (after each meal and before bedtime), rinse orally for 2 minutes then swallow (if pharyngeal involvement) or expectorate, for
1 week Do not eat or drink for 30 minutes following application.
Remove dentures if applicable and consider adding a few drops of nystatin suspension to the water used for soaking acrylic prostheses For patients with natural teeth, emphasize the importance of good oral hygiene due to the high sugar content (50%) in nystatin suspension Additionally, advise patients with removable maxillary prostheses to regularly brush their palate to maintain oral health.
Nystatin pastilles or troches 200,000 IU (Mycostatin ® ) Dsp: #80
Sig: Dissolve 1 pastille in mouth 4 times daily as a lozenge for 14 consecutive days.
Note: Remove denture(s) if applicable If dentate, good oral hygiene should be reinforced because nystatin suspension has high sugar content Advise the patient
23 to regularly brush her or his palate if she or he has a removable maxillary prosthesis Do not chew the pastille More effective than the oral suspension.
Nystatin topical powder 100,000 IU (Mycostatin ® topical powder)
For optimal denture care, apply a generous amount of the solution to the tissue side of a clean denture after each meal and after rinsing Additionally, soak the denture overnight in a mixture of 1 teaspoon of powder and 8 ounces of water for thorough cleaning.
For individuals with natural teeth, it is crucial to maintain good oral hygiene, especially since nystatin suspension contains a high sugar content Additionally, patients with a removable maxillary prosthesis should be advised to regularly brush their palate to ensure optimal oral health.
Nystatin ointment 100,000 IU (Mycostatin ® , Nilstat ® , generic)
To treat denture-related candidiasis and angular cheilitis, apply a thin film of the product to the affected area and the inner surface of the denture after each meal and at bedtime until healing occurs Avoid eating or drinking for 30 minutes post-application This affordable treatment features a polyethylene and mineral oil gel base and can be combined with a topical steroid ointment Additionally, it is offered in an aqueous vanishing cream formulation.
Nystatin 100,000 units/g—triamcinolone acetonide 0.1% ointment (Mycolog II ® , Mytrex ® )
Sig: Apply to the corner of the mouth after each meal and at bedtime until healing occurs.
Intraoral antifungal treatment may be necessary, particularly for denture wearers Nystatin ointment can be effectively applied as a thin film on the inner surface of dentures to combat fungal infections.
Nystatin 100,000 units/g—triamcinolone acetonide 0.1% ointment (Mycolog II ® , Mytrex ® ) and erythromycin gel 2%
Dsp: Compound 30 mg of Mycolog II and 30 mg of erythromycin gel in a 1:1 ratio
Sig: Apply to corner of the mouth after each meal and
1 / 2 hour before bedtime until healing occurs.
Use: Especially useful for recalcitrant angular cheilitis that has been secondarily infected with Staph aureus.
Caution: Ensure patient is not allergic to erythromycin.
1% clotrimazole vaginal cream (Gyne-Lotrimin ® ) Dsp: 1 tube (15 g, 30 g, 60 g, or 90 g)
Sig: Apply small dab to corner of mouth, 4 times a day OR apply small dab to tissue side of denture or to infected oral mucosa 4 times a day.
Sig: Dissolve 1 / 2 vaginal tablet, in mouth, as a lozenge twice daily for 14 consecutive days.
Remove dentures if necessary, and avoid eating or drinking for 30 minutes after application This product serves as an affordable alternative to Clotrimazole prescription cream, though some users may experience a strong bitter taste, which can be alleviated by sipping milk.
2% miconazole nitrate vaginal cream (Monistat 7 ® ) Dsp: 45 g tube
Sig: Apply to affected area and tissue side of denture
Use: Oral candidiasis (denture sore mouth); angular cheilitis.
Immunosuppressives, Occlusive Dressings,
0.5% hydrocortisone acetate ointment (Orabase HCA ® ) Dsp: 5 g tube
Sig: Dry area and then apply thin fi lm to oral sores after meals and at bedtime Do not rub in.
Use: Oral erosive lichen planus, bullous pemphigoid, oral pemphigus, contact (delayed) allergic stomatitis, recurrent aphthous stomatitis, chapped (cracked) lips.
Delmopinol HCl mouth rinse 2 mg/ml (Decapinol ® ) Dsp: 1 bottle
Sig: Use twice daily after brushing and fl ossing. Use: Reduce gingivitis
Classified by the FDA as a bioadhesive device rather than a drug, this product creates a physical barrier that effectively prevents the aggregation and colonization of bacteria at the interface of teeth and gums, without possessing antimicrobial or antiseptic properties.
OVER-THE-COUNTER OCCLUSIVE DRESSINGS
Use: Dry socket (alveolar osteitis)
Sig: Apply 2 dry mucoadhesive discs over the aphthous ulcer on the fi rst day; and then 1 disc each succeeding day.
Benzoin tincture saturated swabsticks (Aplicare, Inc.,
Dsp: 1 case—10 boxes of 50 single sterile swabstick pouches
Use: Topical skin adhesive that prepares the skin for maximum adhesion of dressing or bandages.
Note: Can be removed with acetone alcohol or alcohol; order number is S-1106.
BetaCell oral rinse (micellized retinyl palmitate, micellized D-alpha-tocopheral, micellized beta carotene, glycerin)
Sig: Swish 10 ml in the mouth for 60 seconds in the morning and in the evening and expectorate.
Note: No alcohol or sugar; natural spearmint fl avor; unpublished fi ndings purport reversal of hyperkeratosis and dysplasia.
Use: Gingival irritations, denture sores, aphthous ulcers, burns, orthodontic appliance sores, and oral leukoplakia (see note).
Canker Cover ® mint fl avor (oral canker sore patch)
(menthol, beta-carotene, citrus oil, magnesium chloride, carbomer)
Sig: Apply 1 mucoadhesive patch, white side up, with clean, dry fi nger for 20 seconds.
Use: Recurrent minor aphthous stomatitis.
Note: Do not remove patch before it dissolves If needed, apply a second patch 24 hours after the fi rst application.
Cankermelts ® —GX (1.4 mg glycyrrhizin [licorice root extract])
To effectively treat recurrent aphthous stomatitis and orthodontic-induced ulcers, apply one dry mucoadhesive disc directly over the ulcer for 1–2 minutes as soon as it is detected Maintain the application for at least 16 hours per day, continuing until 8 hours after the soreness subsides Reapply the disc when it has completely dissolved, which typically occurs after 4–6 hours.
For extended use, two discs can be stacked together This product is free from nuts, corn, wheat, rice, grains, soy, eggs, fish, shellfish, milk, and yeast.
Caution: Do not use more than 90 discs in a 3-day period
(30/day) or more than 18 discs every day for 5 days or more Keep out of reach of children younger than age 6 owing to risk of choking.
Gelclair ® bioadherent oral gel (no alcohol; key ingredients: polyvinyl pyrrolodone, hyaluronic acid, glycyrrhetinic acid) Dsp: 15 ml per single-dose packet; 1 box contains 21 single-dose packets
To use the product effectively, take one single-dose packet three times a day or as needed Pour the entire contents into a glass, then add 1 tablespoon of water, adjusting the dilution for your preferred consistency Stir the mixture well and rinse your mouth for at least one minute before expectorating It is important to refrain from eating or drinking for at least one hour after use for optimal results.
Use: For recurrent aphthous ulcers and nonspecifi c small ulcers.
This product is contraindicated for patients with a known hypersensitivity to any of its ingredients While the gel may darken and thicken over time, these changes do not impact its efficacy or safety.
Caution: Keep out of direct sunlight; do not refrigerate.
Orabase ® Sooth-N-Seal (formulated 2-octyl cyanoacrylate)
Dsp: 1 ml (10 uses with 10 applicators)
To treat a mouth sore, apply 2 drops of liquid into a plastic well Use the pointed end of the provided sponge swab to dip into the well, then dry the affected area with the rounded end of the swab Dab the pointed end of the swab on the sore for no longer than one second, and repeat if necessary Ensure that you do not release the lip or cheek for at least 5 seconds after application.
Use: For recurrent aphthous ulcers and nonspecifi c small ulcers.
Warning: This fast-setting adhesive can bond quickly, so be careful to prevent contact with unintended surfaces Avoid eye contact, and do not ingest the product; if accidental ingestion occurs, contact poison control immediately.
Orajel ® Protective MouthSore Discs (benzocaine 15 mg, carbomer, pregelatinized zea mays [corn] starch) Dsp: 1 box (8 discs)
Sig: Apply 1 mucoadhesive disc to sore.
Use: Recurrent minor aphthous stomatitis.
In 2011, the FDA warned that over-the-counter benzocaine gels and liquids used on the gums or mouth can lead to a rare but serious condition called methemoglobinemia It is crucial to avoid using benzocaine products on children under 2 years old, especially for teething, unless directed and monitored by a healthcare professional.
Sig: Apply to affected oral mucosa.
To ensure proper adhesion of the patch, moisten the extremely dry mucosa with water first This patch features a unique nondrug formula that includes time-released lipids, citrus oil, sea salt, enzymes, and xylitol for optimal effectiveness.
OraPatch ® (acemannan hydrogel—a freeze-dried gel of aloe vera; also known as Carrington patch or Manapol patch)
To use the patch effectively, ensure your hands are clean and dry before carefully applying one patch to the affected area of the oral mucosa Avoid squeezing the patch and hold it in place until it adheres properly Keep the area dry to enhance adherence, and use the patch as needed for pain relief.
Use: Originally developed for aphthous ulcers, but has FDA approval for any type of oral traumatic ulcer; most recently approved for dry socket management.
Rincinol P.R.N ® (aloe vera; alcohol-free, no benzocaine or hydrogen peroxide)
Dsp: One 4 oz bottle or 3 on-the-go soft packs per package
Sig: After drying area, pour contents of packet into mouth and rinse for 1 minute and expectorate.
Use: Nonspecifi c oral ulcers, aphthous ulcers, minor oral irritations and burns, denture irritation.
Zilactin-L ® gel (80.8% SD benzyl alcohol 37, 7% tannic acid, 2.5% salicylic acid)
Sig: After drying area, apply a thin coat with clean fi ngertip or cotton-tip applicator over affected tissue every 1–2 hours.
Use: Recurrent aphthous ulcers, abrasions, and herpes simplex lesions.
Systemic steroids should be used with caution in certain conditions, such as diabetes, due to their potential to elevate blood sugar levels; consulting a physician before prescribing is advisable Most oral pathologists agree that tapering prednisone is unnecessary for short-term burst therapy lasting 5 to 7 days or for alternate-day therapy with doses not exceeding 20 mg It's important to avoid steroids in the presence of active infections, as they can promote microbial growth and systemic spread Additionally, baseline hematology tests, including platelet counts, are essential to monitor for possible bone marrow suppression, and hepatotoxicity has also been reported.
Special Advice: In order to reduce the possibility of adrenocortical suppression, it is important that
To align prednisone intake with the body's natural diurnal adrenocortical steroid levels, it is recommended to take the medication 90 minutes after waking up Additionally, administering prednisone on alternate days in the morning can help minimize the risk of adrenocortical suppression.
When gingival lesions are significant, using a soft acrylic splint that covers the attached gingiva can effectively retain topical steroid gel on the mucosal tissues Additionally, the relative potencies of various topical corticosteroids are detailed on page 102.
Sig: Rinse, swish, and expectorate solution 4-5 times daily.
Note: Flavoring agents are optional Rather expensive
84,000 IU nystatin, 84 mg tetracycline, 1.04 mg hydrocortisone/5 ml liquid
Use: Alternate rinse with 2% viscous lidocaine for
2 minutes and expectorate 4 times daily.
Use: Major aphthous ulcer in the immunosuppressed
[Source: Glick M, Muzyka BC JADA 1992;123:61–65.]
Sig: Take graduated doses according to the manufacturer’s instruction Apply spray to back of the oral cavity.
Use: Hard-to-reach oral cavity areas such as the tonsillar pillars.
Note: Improper use can cause a number of oropharyngeal adverse events including candidiasis and dysphonia.
Betamethasone 0.6 mg/5 ml syrup (Celestone ® ) Dsp: 118 ml
Sig: Take 1 tsp 4 times a day Gargle for as long as possible and expectorate.
Use: Oral erosive lichen planus, bullous pemphigoid, oral pemphigus, contact (delayed) allergic stomatitis, recurrent aphthous stomatitis.
Note: Taking with food may minimize gastrointestinal distress.
Caution: Not recommended for supplementary use in corticosteroid-treated patients undergoing stress; also increased susceptibility to infection.
Sig: Apply to oral sores 4 times daily (after meals and at bedtime).
Use: Oral erosive lichen planus, bullous pemphigoid, oral pemphigus, contact (delayed) allergic stomatitis, recurrent aphthous stomatitis.
Note: Taking with food may minimize gastrointestinal distress.
Caution: The product is labeled for external use only; however, patients may be advised to disregard this warning for off-label use In the event of candidiasis, it is recommended to incorporate 100,000 units of nystatin into each gram of the ointment.
0.1% betamethasone valerate ointment (Valisone ® ) Dsp: 15 g (45 g, 110 g, 430 g) tube
Sig: Apply thin amount to oral sores 4 times daily (after meals and at bedtime).
Use: Oral erosive lichen planus, bullous pemphigoid, oral pemphigus, contact (delayed) allergic stomatitis, recurrent aphthous stomatitis, chapped (cracked) lips. Note: Taking with food may minimize gastrointestinal distress.
Caution: Prolonged use can result in tissue thinning.
0.05% clobetasol propionate gel or ointment
Sig: Dry area and apply to oral lesions 4–6 times daily (after meals and at bedtime) Do not rub in.
Oral conditions such as erosive lichen planus, bullous pemphigoid, oral pemphigus, delayed allergic stomatitis, recurrent aphthous stomatitis, and chapped lips can be effectively treated with a gel formulation, which offers slightly lower potency than ointment For denture wearers, it's important to apply a thin film of the gel to the inner surface of the denture base where it comes into contact with oral lesions to ensure optimal relief and healing.
0.05% clobetasol propionate ointment (Temovate or generic) with Orabase or Orabase with benzocaine Dsp: 30 g tube (15 g each, compounded 1:1)
Sig: Dry area and apply to oral lesions 4–6 times daily (after meals and at bedtime) Do not rub in Do not eat or drink anything for 1 / 2 hour after use.