A Dental Nurse's Guide to Pharmaceuticals
Pharmaceuticals can be prescribed to dental patients for a number of reasons. These range from controlling pain and relieving anxiety to preventing infection and managing a medical emergency.
Though dental nurses are not able to supply or administer medicines without the prescription of a dentist, having a basic understanding of the most common types of dental pharmaceuticals is important.
Most of the pharmaceutical products mentioned and linked to in this article are prescription only medicines and only available to purchase by GDC registered dentists.
Please note this article is for educational purposes only and should not be considered medical advice nor a substitute for the expertise of a suitably qualified professional.
Analgesics are pharmaceuticals used primarily to relieve analgesia (mild to moderate pain). Some analgesics also have an anti-inflammatory effect.
Non-steroidal anti-inflammatory drugs (NSAIDs) are one type of analgesic. Well known NSAIDs include aspirin and ibuprofen. NSAIDs act peripherally, meaning they help with pain by reducing inflammation at the site where it is occurring.
The other main type of non-opioid analgesic is paracetamol, which is not anti-inflammatory. Paracetamol acts centrally by blocking the transmission of pain signalling within the central nervous system.
For moderate to severe acute pain, weak opioid analgesics are sometimes used. Opioids work by altering the nervous system’s response to painful stimuli. Examples of weak opioids include codeine and dihydrocodeine. Fixed dose combinations of opioids and paracetamol are sometimes prescribed for pain relief. Care needs to be taken when prescribing opioids as they may have addictive properties.
The BDA recommends non-opioid analgesics as the first line measure for dental post-operative pain in accordance with the WHO analgesic ladder.
The National Institute for Health and Care Excellence (NICE) issues the following advice for prescribing analgesics:
- A full therapeutic dose of one drug should be used before considering switching to a different analgesic or adding another analgesic.
- The underlying cause of the pain should be treated whenever possible.
- People who experience continuous pain should receive regular analgesia following a full clinical assessment.
- Combination analgesics should be avoided as first-line treatment. Prescribing single constituent analgesics allows independent titration of each drug.
Analgesics are normally delivered orally via tablets or capsules.
Local anaesthesia is commonly used in dental procedures to numb pain in a specific area of the tissues of the mouth. The patient remains fully conscious during treatment.
Local anaesthetics are the predominant choice for fillings, extractions, root canal and crown placement.
Administration is normally done by injection: infiltration injection (numbing a small area at the site of the injection) or block injection (numbing an entire region of the mouth by administering anaesthesia to a nerve).
It can also be given as a topical ointment, via spray or drops.
The most widely used local anaesthetics are:
Articaine: Anaesthetics such as Septanest contain articaine hydrochloride (anaesthetic) and adrenaline (epinephrine). The adrenaline acts as a vasoconstrictor which helps to prolong the effect of the articaine, keep the anaesthetic where it needs to be, and control bleeding.
Lidocaine: Xylocaine contains lidocaine hydrochloride (local anaesthetic) and adrenaline (epinephrine). Lidocaine is generally preferred for pregnant patients.
Mepivacaine: Scandonest consists of mepivacaine hydrochloride (local anaesthetic) without adrenaline. Mepivacaine has a shorter duration of action compared to lidocaine and articaine anaesthetics. However, it is avoided for pregnant patients.
Prilocaine: Citanest has the longest soft tissue duration.
All anaesthetics are used with caution with clinically vulnerable patients: children, the elderly, pregnant women and patients in poor health. Contraindications can be identified by the dentist by reviewing the patient’s current medical conditions and state of health prior to treatment.
Learn more about local anaesthetics in our blog ‘Dental Anaesthetics – An Essential Overview’.
Antibiotics are used frequently by dentists to prevent and treat bacterial infections.
Administration of antibiotics is not without its risks, so as with all drugs they are carefully prescribed. It is also important to minimise the use of antibiotics in order to reduce the chance of antibiotic-resistant infections developing.
The most widely used types of dental antibiotics in the UK include:
Amoxicillin – Amoxicillin is a type of penicillin antibiotic and the most common antibiotic prescribed by dentists worldwide, according to the Internal Dental Journal (IDJ). It used to treat many types of bacterial infections, including tooth infections.
Metronidazole – Metronidazole is an antibiotic used to treat infected gums and dental abscesses. It is the primary drug prescribed for acute ulcerative gingivitis. Sometimes uses alongside amoxicillin.
Penicillin V – Penicillin V is a type of Phenoxymethylpenicillin antibiotic administered orally to patients. Its common uses include treatment against acute oral infections such as dental abscesses, salivary gland infections and post-extraction infection. Sometimes used alongside amoxicillin.
Erythromycin - Erythromycin is a wide spectrum antibiotic with a similar range on the antibacterial spectrum to penicillin, making it the ideal first choice if patients are allergic to penicillin.
To learn more about the prescribing of antibiotics in dentistry, see the Faculty of General Dental Practice’s (FGDP) Good Practice Guidelines.
All members of the dental team should be familiar with these pharmaceuticals and what type of medical emergencies they are used to manage. However, it’s important to understand which members of the dental team are permitted to administer each drug.
For example, adrenaline and glucose are not covered by the Medicines Act 1968, and therefore could potentially be administered to patients by any member of the team. However, it is important that the person administering the drug has both the competence and expertise to do it. Your dentist will be able to advise on the extent to which you should assist with providing first aid to patients, including providing assistance with emergency drugs.
Adrenaline/epinephrine – Given as an intramuscular injection as first line treatment for anaphylaxis, a severe and life-threatening allergic reaction. Epinephrine is often delivered with an EpiPen, an auto-injectable device.
Salbutamol – Given to patients suffering an asthma attack in the practice. Most often delivered in the form of an inhaler.
Glyceryl trinitrate or GTN – Used in the initial management of patients suffering from myocardial infarction (MI), more commonly known as a heart attack. Typically delivered orally with either tablets or spray.
Oxygen – High flow oxygen can be used for the initial management of MI, initial management of anaphylaxis and on patients suffering seizures to support respiration if necessary.
Glucose - Given to patients suffering from hypoglycaemia, which is when the glucose level (blood sugar level) is too low. Commonly delivered in the form of a liquid, tablet or gel.
To learn more about the importance of basic first aid training and managing medical emergencies, see our blog ‘Why Every Dental Practice Should Undertake Basic First Aid Training’.
Sedation drugs, commonly referred to as sedatives, are used to calm and relax patients or induce sleep.
Moderate sedatives are sometimes called “conscious sedation” drugs because though the patient is still conscious, the drug creates a short-term amnesia in the patient who becomes insensitive to pain.
The most widely used types of sedation drugs in dentistry include:
Nitrous Oxide – Commonly known as laughing gas. Nitrous oxide is inhaled through a mask or nosepiece. The use of nitrous oxide is less common in modern dentistry.
Midazolam - Midazolam belongs to a group of medicines called benzodiazepines, to which Diazepam also belongs. It is used to decrease patient anxiety and has the effect of short-term memory loss. Midazolam can be given by mouth, intravenously, intramuscularly, by spraying into the nose, or through the cheek
The midazolam solution should be placed against the sides of the gums and cheek so that the medicine is absorbed directly into the bloodstream. This is known as the buccal or oromucosal route
Typically, the sedation lasts between 60 and 120 minutes in total.
Midazolam and diazepam are also used to treat ongoing seizures, known as “status epilepticus”. This life-threatening condition involves the patient experiencing a seizure lasting more than 5 minutes, or the having more than one seizure within a 5-minute period. Rapid treatment is vital to reduce the risk of permanent damage to the brain.
As such, Midazolam is typically found within a dental practice’s “emergency drug kit”. As a prescription drug is may only be administered by the dentist.