Pharmacology
What is fair game
Local anesthetics, analgesics, antibiotics, anxiolytics and sedation, emergency drugs, and drug interactions.
Local anesthetics
Amides (lidocaine, mepivacaine, articaine, prilocaine, bupivacaine) are metabolized mainly in the liver, except articaine (plasma esterases) and prilocaine (lung and liver). Esters (benzocaine, procaine) are hydrolyzed by plasma pseudocholinesterase and are more allergenic. pKa governs onset, lipid solubility governs potency, and protein binding governs duration. Epinephrine prolongs duration and improves hemostasis, but limit to about 0.04 mg in significant cardiac disease.
Analgesics
NSAIDs are first-line for dental pain (ibuprofen 400–600 mg every 6 hours), and adding acetaminophen improves analgesia. Opioids are adjuncts for severe pain and should be short-course. Avoid aspirin in children because of Reye syndrome, and use NSAIDs cautiously in renal disease, peptic ulcer, and third-trimester pregnancy.
Antibiotics
Amoxicillin is first-line for odontogenic infection; penicillin-allergic patients receive clindamycin or azithromycin. Prophylaxis is limited to specific cardiac conditions: 2 g amoxicillin 30–60 minutes before the procedure.
Interactions and special populations
Warfarin plus NSAIDs or antibiotics raises bleeding risk - check INR and consult. Macrolides and azoles inhibit CYP3A4 and raise levels of some co-administered drugs. Bisphosphonates and antiangiogenic agents carry medication-related osteonecrosis risk and require planning before extraction.
Traps
Antibiotics never substitute for drainage. Palpitations and tremor after injection usually reflect epinephrine, not allergy.
Rule of thumb
Clark's rule for pediatric dosing: child dose = adult dose × (weight in pounds ÷ 150).