Analgesics
Acetyl-salicylic acid
Class
– Non-steroidal antiinflammatory drug (NSAIDs).
Indications
– Mild pain.
Main side effects
– Gastric irritation and interference with haemostasis.
Contraindications
– Peptic ulcer, bleeding, asthma, paediatric age group, advanced pregnancy,
renal diseases, allergy to acetylsalicylic acid.
Interactions
– Corticosteroids and other NSAIDs (risk of peptic ulcer), allopurinol
(reduces the effects), and oral antidiabetic drugs (increases the effects).
Adult dose
– 300-600 mg up to 6 times daily/daily after meals.
Codeine
Class
– Opiate.
Indications
– Moderate pain.
Main side effects
– Nausea, headaches, drowsiness, constipation, and xerostomia.
Contraindications
– Hepatic diseases and advanced pregnancy.
Interactions
– Antihistamines, antidepressants, hypnotics and sedatives (increase sedative effects), monoamine oxidase inhibitors, alcohol, cocaine and cannabis (serious toxicity),
warfarin (bleeding), analgesics (increases the effects), zidovudine (increases toxicity).
Adult dose
– 10-60 mg.
Diclofenac
Class
– NSAID.
Indications
– Moderate pain.
Main side effects
– Gastric irritation, nausea.
Contraindications
– Peptic ulcer, pregnancy, hypersensitivity to acetylsalicylic acid.
Interactions
– Corticosteroids and other NSAIDs (risk of peptic ulcer),
lithium (increases plasma levels), ciclosporin (increases renal toxicity).
Adult dose
– 25-75 mg, up to twice daily.
Antibacterial Agents
Amoxicillin
Class:
– Penicillin.
Indications:
– Oral bacterial infections.
– Staphylococcus aureus is often resistant.
Main side effects
– Rare.
– Diarrhoea, reactions due to hypersensitivity.
Contraindications
– Hypersensitivity to penicillin, toxic dermatitis during mononucleosis, cytomegalovirus infection, lymphoid leukaemia, therapy with allopurinol.
Interactions
– Probenecid (prolongs blood levels of amoxicillin), hypersensitivity induced by cephalosporin.
Adult dose
– 250-500 mg, 8-hourly.
Ampicillin
Class
– Penicillin.
Indications
– Oral bacterial infections.
Main side effects
– Rare.
– Pain and inflammation of injected area. Nausea, vomiting, diarrhoea, hypersensitivity.
Contraindications
– Hypersensitivity.
Interactions
– Probenecid (prolongs and extends the blood l levels of ampicillin),
allopurinol (skin reactions to the ampicillin).
Adult dose
– 250-500 mg, 8-hourly.
Azithromycin
Class
– Macrolide.
Indications
– Oral bacterial infections.
Main side effects
– Rare.
– Diarrhoea, abdominal pain, nausea, vomiting.
Contraindications
– Hypersensitivity to azithromycin and other macrolides, serious hepatic failure.
Interactions
– Do not administer with antacids.
Adult dose
– 500 mg daily.
Cefadroxil
Class
– Cephalosporin. Acts orally.
Indications
– Oral bacterial infections.
Main side effects
– Rare.
– Hypersensitivity.
Contraindications
– Hypersensitivity.
Adult dose
– 1-2 g, 2 times/daily.
Cefazolin
Class
– Cephalosporin.
Indications
– Oral bacterial infections.
Main side effects
– Rare.
– Localised pain after injection.
– Hypersensitivity.
Contraindications
– Hypersensitivity.
– Reduce dosage in case of renal failure.
Interactions
– Probenecid (prolongs and extends the blood levels of amoxicillin), aminoglycosides and diuretics (increase renal toxicity).
Adult dose
– 1-2 g/daily intramuscular or intravenous, 4 times /daily.
Clarithromycin
Class
– Macrolide.
Indications
– Oral bacterial infections.
Main side effects
– Rare.
– Diarrhoea, abdominal pain, nausea, headaches, skin rash.
Contraindications
– Hypersensitivity, pregnancy, during breast-feeding and serious hepatic failure.
Interactions
– It increases the blood haematological levels of carbamazepine and theophylline.
Adult dose
– 250 mg, 2 times /daily.
Clindamycin
Indications
– Serious oral bacterial infections in case of allergy to penicillin.
Main side effects
– Nausea, vomiting, diarrhoea, pseudomembranous colitis.
Contraindications
– Hypersensitivity.
Interactions
– It can enhance the blocking effect of neuromuscular drugs like pancuronium;
adverse reaction with erythromycin.
Adult dose
– 10-30 mg/kg/daily, 4 times/daily.
Metronidazole
Indications
– Acute necrotising gingivitis, periodontal diseases.
– Effective against anaerobic microbes.
Main side effects
– Nausea, diarrhoea, bad taste, peripheral neuropathies (especially in patients with liver disease).
Contraindications
– Pregnancy.
Interactions
– Warfarin (increases its effects), alcohol (disulfiram-type reactions).
Adult dose
– 200-400 mg, 8-hourly (take with meals).
Minocycline
Class
– Tetracycline.
Indications
– Mucous membrane pemphigoid.
– Used for its anti-inflammatory activity.
Main side effects
– It can cause vertigo, oral and skin pigmentation.
Contraindications
– Pregnancy and children.
Interactions
– Not known.
Adult dose
– 100-200 mg/daily.
Vancomycin
Class
– Glycopeptide.
Indications
– Oral bacterial infections in patients allergic to penicillin.
Main side effects
– Nausea, fever, phlebitis, rashes, hearing loss, nephrotoxicity.
Contraindications
– Renal or auditory impairment.
Interactions
– None.
Adult dose
– 500 mg, 4 times/daily (orally or intravenously) or 1g, 2 times/daily intravenously.
Antifungal Agents
( For Oral Candidosis )
Amphotericin (topical)
Indications
– Mild candidosis.
Main side effects
– None.
Contraindications
– None.
Interactions
– None.
Adult dose
– 4-5 daily mouth washes (oral suspension 100 mg/mL).
Fluconazole
Indications
– Useful against candidosis resistant to standard topical treatments,
especially in subjects with immunosuppression.
Main side effects
– Abdominal pain, nausea, diarrhoea, hepatic toxicity.
Contraindications
– Pregnancy, children with renal disease. Less hepatotoxic than ketoconazole.
Interactions
– Same as ketaconazole (below).
Adult dose
– 50-100 mg, daily; 2-3 daily mouth washes (suspension).
Itraconazole
Indications
– Useful against candidosis resistant to standard treatments.
Main side effects
– Nausea, vomiting, headaches, rash, oedema.
Contraindications
– Pregnancy and breastfeeding.
Interactions
– Absorption is reduced by antacids; it increases the effects of ciclosporin,
hypoglycaemic agents, diciumarol, digitalis and antihistamines.
Adult dose
– Each tablet contains 200-400 mg, daily.
Ketoconazole
Indications
– Useful against candidosis resistant to standard treatments.
Main side effects
– Nausea, hepatic toxicity.
Contraindications
– Pregnancy, patients with chronic hepatic disease.
Interactions
– Cimetidine and ranitidine (absorption reduced), isoniazid and rifampicin
(effect reduced), antidiabetic drugs (increase the effects).
– It increases the nephrotoxicity of ciclosporin.
Adult dose
– 200-400 mg, daily.
Nystatin
Indications
– Candidosis in immunocompetent subjects.
Main side effects
– Unpleasant taste, nausea, gastric conditions.
Contraindications
– None.
Interactions
– None.
Adult dose
– 4-6 daily mouth washes (oral suspension 100000 units per mL).
Miconazole (topical)
Indications
– Candidosis in immunocompetent subjects.
– In theory, better antifungal for the treatment of angular cheilitis.
Main side effects
– Nausea.
Contraindications
– None.
Interactions
– None.
Adult dose
– 3-4 daily applications of 5 mL gel (25 mg/mL).
Antiviral Agents
( Oral herpetic infections )
Acyclovir
Indications
– Primary and recurrent herpes simplex virus infection (HSV), and varicella-zoster virus infection (VZV).
Main side effects
– Headaches, gastric conditions, rash.
Contraindications
– Pregnancy.
Interactions
– It increases the renal toxicity of gentamicin, vancomycin, amphotericin
and ciclosporin, zidovudine, interferon, alcohol and cocaine (neurological changes).
Adult dose
– 5 tablets daily (of 200-400 mg, one every 4 hours) until the primary HSV infection has cleared, for recurrent labial infections and intraoral and for varicella; 800 mg,
5 tablets daily for the zoster.
– Cream (5%): 4-6 daily applications for recurrent labial lesions.
– 250 mg/m2 IV every 8 hours for immunocompromised patients.
Foscarnet
Indications
– Aciclovir-resistant HSV or VZV.
Main side effects
– Nephrotoxicity, nausea, vomiting, anaemia, fatigue.
Contraindications
– Renal disorders.
Interactions
– Renal toxicity increases with amphotericin B, pentamidine and aminoglycosides;
pentamidine increases the risk of hypocalcaemia.
Adult dose
– 40 mg/kg, daily intravenous every 8 hours.
Penciclovir
Indications
– Primary and recurrent herpes simplex virus infection (HSV).
Main side effects
– None.
Contraindications
– None.
Interactions
– None.
Adult dose
– Cream 1%; 1 application every 2 hours/daily (during the day).
Valaciclovir
Indications
– Varicella-zoster infections.
Main side effects
– Nausea, headaches, vomiting.
Contraindications
– Immunocompromised patients.
Interactions
– Cimetidine and probenecid reduce haematological problems.
Adult dose
– 1g, 3 times daily.
Corticosteroids
1. Topical corticosteroids
– The European Classification System has four levels numbered I to IV in descending order of potency to classify the clinical potency of corticosteroids:
– Very potent (class I).
– Potent (II).
– Moderately potent (III).
– Midly potent (IV).
– Class I and II of topical steroids are usually preferred for the oral cavity, especially in the treatment of erosive bullous diseases.
– In the case of minor aphthae, a less potent cortisoid might be used.
– The greatest problem when using topical corticosteroids in the oral cavity
is to make adherence to the mucosa possible for as long as it is necessary in order to carry out the treatment.
– For this, adhesive gels are used, which have a base of carboximethylcellulose (for instance, Orabase1) or hydroxyethylcellulose (to 4%) that are mixed in equal parts (50:50) with the topical steroid.
– They are often used as an ointment because creams have a bitter taste and the gels can burn because they usually contain alcohol.
– In any case, it is possible to use salves that provide the paste with greater consistency but less adherence.
– In the case of gingival lesions, it is often useful to use a tray prepared in transparent soft resin or silicone that allows occlusive therapy.
– The most frequent side effect during a course of topical steroid treatment is candidosis, which is easily prevented with the help of antifungal treatments
in the form of chlorhexidine mouthwash and miconazole gel.
Triamcinolone acetonide
Indications
– Moderately potent (III).
Main side effects
– Oral candidosis.
Contraindications
– None.
Interactions
– None.
Adult dose
– 3-6 daily applications.
Fluocinonide
Indications
– Erosive-bullous diseases.
– Used with adhesive gels of carboximethylcellulose (Orabase); potent (II).
Main side effects
– Oral candidosis.
Contraindications
– zNone.
Interactions
– None.
Adult dose
– 3-6 daily applications.
Clobetasol propionate
Indications
– Erosive-bullous diseases.
– Used with adhesive gels of carboximethylcellulose (Orabase); very potent (class I).
Main side effects
– Oral candidosis.
– Very rarely adrenocortical suppression.
Contraindications
– None.
Interactions
– None.
Adult dose
– 2-3 daily applications.
2. Systemic corticosteroids
Prednisone
Indications
– Severe erosive-bullous diseases (pemphigus mucous membrane pemphigoid,
erythema multiforme, and sometimes erosive lichen planus and major aphthae or herpetiform ones).
Main side effects
– Gastric irritation, mood swings, insomnia, water retention, hyperglycaemia, weight gain, arterial hypertension, osteoporosis, adrenocortical abolition
(Cushingoid aspect).
Contraindications
– Pregnancy, osteoporosis, decompensated diabetes, peptic ulcer, hepatic diseases, and psychosis.
Interactions
– Anticoagulants and oral antidiabetics (they reduce the effects), NSAIDs (increases the risk of peptic ulcer), furosemide (hypopotassaemia).
Adult dose
– 0.5-25 mg/kg orally, once/daily.
Other Immunomodulant Drugs
Azathioprine
Indications
– Severe erosive-bullous diseases (pemphigus or mucous membrane pemphigoid).
– Together with corticosteroids in order to improve their
immunosuppressant effectiveness.
Main side effects
– Myelosuppression and hepatic toxicity.
– Chronic use might make the subject susceptible to malignant tumours.
Contraindications
– Pregnancy.
Interaction
– Allopurinol (it increases azathioprine action), acetylsalicylic acid (bleeding),
other immunosuppressants (increased risk of infections).
Adult dose
– 2-2.5 mg/kg orally.
Ciclosporin (topical)
Indications
– Severe erosive-bullous diseases (pemphigus, mucous membrane pemphigoid,
and erosive lichen planus).
– It can be used as a mouthwash or adhesive base similar to Orabase.
Main side effects
– Renal and hepatic toxicity, hypertension, and gingival hyperplasia.
– All these side effects are rare when the drug is used topically.
Interactions
– Allopurinol, analgesics and antifungals (increase toxicity of ciclosporin), antiepileptic drugs (reduction of effects)
Adult dose
– 1-10 mouth washes, daily (oral suspension 100 mg/mL); 1-2 daily applications
in adhesive base similar to Orabase.
Dapsone
Indications
– Mucous membrane pemphigoid.
Main side effects
– Anaemia, rash, neuropathy, headaches, renal and hepatic toxicity.
Contraindications
– Deficit of glucose-6- phosphate dehydrogenase, pregnancy, and
cardiorespiratory diseases.
Interactions
– Trimethoprim and methotrexate increase the risk of haematological complications.
Adult dose
– 5 mg, daily for the first three days, then 10 mg, daily for the next three days, and then 15 mg, daily for the next three days; then 20 mg, daily.
Tacrolimus (topical)
Indications
– lichen planus, pemphigoid.
Main side effects
– Burning sensation.
Contraindications
– None.
Interactions
– None.
Adult dose
– 1-2 daily applications.
Other Drugs
Carbamazepine
Indications
– Trigeminal neuralgia.
Main side effects
– Occasional vertigo, diplopia and haematological dyscrasia, usually with rash in the first three months of treatment.
Contraindications
– Deficit of glucose-6- phosphate dehydrogenase, pregnancy,
and cardiorespiratory diseases.
Interactions
– Enhanced by cimetidine and isoniazide, it increases the effect of lithium; it interferes with oral contraceptives.
Adult dose
– Usually start with 200 mg, daily.
– Many patients need 200 mg every 8 hours; do not exceed 1800 mg, daily.
Pilocarpine
Indications
– Xerostomia.
Main side effects
– Sweating, bradycardia, tachycardia, hypotension-hypertension, and biliary spasm.
Contraindications
– Hypertension, cardiovascular diseases, arrhythmia, psychosis,
urinary lithiasis and biliary diseases.
Interactions
– Betablocker (risk of arrhythmia), anticholinergic (compromises its effects), cholinergic (increases its action).
Adult dose
– 1 teaspoon, 1-4 times daily (solution 5 mg/mL).
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