Extraction Complications

The common complications of the extracted wound are bleeding and pain.

Bleeding
In some cases, the patient's medical health status and the drugs taken influenced the blood coagulation. These patients present either medically anticoagulated for thrombosis, heart valve replacement,  atrial fibrillation, stroke, and embolism or inherited coagulopathies as in the case of hemophilia.  It is wise to consult with the patient's physician before the operation to prepare for the best management strategy. To select the best strategy for the patient, the dentist must understand the function of various drugs used in anticoagulation therapies. Some of the drugs used in anticoagulation are:

• Coumadin (Warfarin) used to block the extrinsic coagulation pathway with an effective half-life of three days.  The blood coagulation process level appropriates for surgery of the patient who discontinues Coumadin occurs in three days.
• Aspirin works by interfering with blood platelet adhesion and last throughout the life of the blood platelet.  Therefore, the patient needs to discontinue the drug seven days before surgery.
• The following herbal supplements may keep the patient's blood from clotting: garlic, ginger, St. Johns Wort, Chondroitin sulfate, Turmeric, fish oil, Ginseng, and Gingko Biloba

Some of the techniques the dentist used to prevent and treat the prolong bleeding are as follow:

1. Removal of all granulation tissue and tooth remnants from the socket
2. Avoid traumatize the soft tissue around the socket
3. Adequate irrigation to keep the socket clean
4. Pack the socket with hemostatic agents such as Gel-foam, Surgicel, Helistat, Sulzer, or Avitene Davol
5. Appropriate closure of the wound by suturing if necessary
6. Instruct the patient to bite down on gauze for 20-30 minutes 
7. Recommend the patient to avoid rinsing the mouth and smoking for 24 hours
8. Avoid eating hot foods or drinks
9. When the patient reports bleeding at home, advise the patient to moisten the tea bag in cool water before biting on it for 20 minutes (Tannic acid in tea helps blood clot)
10. If the bleeding persists, ask the patient to return to the office for an assessment.  Some patient may develop an incomplete blood clot that requires re-cleaning the socket to allow the most stable clot to form.

Pain after dental extraction should not last more than three days.  Call your dentist for an assessment if there is increased pain after three days.  If you cannot reach the dentist, follow the instruction of managing pain at home from this site.

Dental Decay (Dental Cavity, Dental Caries)

To know how to prevent dental decay, we need to know how it forms

Dental decay based on studies by Fitzgerald and Keyes (1960) is an infectious and transmittable micro-biologic disease of the tooth that results in localized dissolution and destruction of the calcified tissues (enamel).  It is the most prevalent condition affecting over 2 billions people worldwide.

There are many different types of bacteria in our mouths, but only some that are known to associate with cavities.  The most common bacteria include Streptococcus Mutans, Lactobacillus Casei and Acidophilus, and Actinomyces Naeslundii.

Other environmental factors that influence cavitation in the enamel are:

• Acidic condition in the saliva can erode (demineralize) the enamel (the outermost layer of the tooth), results in a cavity
  
  
• Routinely consume diets rich in sugars and starchy foods.  The by-product aAfter bacteria digest simple carbohydrates (sugars, starchy foods) is acid.  Prolong exposure to these foods results in larger cavities and more teeth involvement.

Recent year, researchers found that dental decay has more complex factors than previously described by FItzgerald and Keyes. And they also found that dental decay is a non-infectious disease with site-specific, preventable and reversible.  The new concept involves the balance between 2 factors:

1. Risk factors: include acid producing microorganism, diets rich in carbohydrates, the change of the status of the saliva (composition, flow rate, ph), dental plaque (biofilms)
2. Protective factors: include fluoride exposure, the flow rate and ph of the saliva, and good oral hygiene

Dental caries develops when risk factors overwhelm the protective factors for a long period of time or with high frequency .  Other elements that play important role in the development of dental caries are genetics, immune system, lifestyle, age, socio-economic status, and an anatomy of the tooth.

The process of dental tooth caries

First stage;
In general, tooth structure oscillates between demineralization - loss of minerals (calcium phosphate) at low pH and remineralization - gain minerals at the more neutral or high pH.

Researchers found the dental plaque at the tooth surface was a primary cause of lower pH in the oral cavity. During demineralization, the surface color and texture of enamel may change to brown. As long as the enamel remains intact, remineralization can occur, allowing calcium and phosphate to return to enamel matrix substructure.  At this stage, no filling is necessary.  Observation in this area is indicated to see if the dental cavity proceeds to the second phase.

Second stage;
Dental caries becomes deep, extensive breakdown of the enamel occurs, exposing a dentin (second layer of tooth structure).  At this point, remineralization is not possible, a filling is necessary. In some cases, any stimuli such as heat, cold and tactile sensation may trigger sensitivity to mild pain. The dentin itself has no nerve or blood vascular system, but the sensation travels through the exposed dental tubules in the dentin to the nerve in dental pulp chamber at the center of the tooth.

Third stage;
Dental caries penetrates deeper inside the tooth, exposing the nerve fibers, arteries, veins and lymphatic vessels in the pulp chamber.  Patients may experience severe pain. Root canal treatment is a treatment of choice.  Without any treatment, the tooth breaks down; infection begins at the root tip causing bone destruction and intensified pain.

The development of dental cavity

How to stop the decay
According to the California Dental Association Journal published in January 2016, the use of Silver Diamine Fluoride (SDF) has been found to arrest and prevent dental caries.  What makes SDF effective against decay is the silver component kills the bacteria and stop the decay, while fluoride hardens what is left through remineralization.  SDF has been approved by the U.S. Food and Drug Administration in 2014 for tooth hypersensitivity but dentists around the world had been used SDF off label to arrest decay with high success in an active, non-symptomatic carious lesion for decades. Consult with your dentist if SDF can be applied to your cavity.  The final restoration of the decayed tooth is still necessary to restore the full function of the tooth.  The CDT code for dental insurance claim is 1354: Interim caries arresting medication application.

Here are some suggestions for preventing dental caries:

1. Diets:
Be selective in your diets. Eat whole foods, vegetables, and fruits.  Avoid sour candies, carbohydrate-containing foods that can feed bacteria made it readily adhere to tooth surface, e.g.,

• White rice
• Bread and pasta made from white flour 
• Most packaged cereals
• Highly processed, sugar-containing foods such as candy, cake, corn syrup
• Fruit juice
• Soft drink.  

2. Proper flossing before brushing your tooth.  Flossing removes dental plaque and food remnants between the teeth, prevents cavities at the contact between the teeth

3. Proper brushing technique: Improve your oral hygiene; learn how to brush your teeth properly and maintain regular cleaning after eating by flossing and brushing.  Ask your hygienist to demonstrate the proper way to clean your teeth if you are unsure of your method.  Include water irrigation such as Waterpik Ultra Water Flosser into your cleaning routine.  Learn how to use water irrigation from here.

4. Type of Toothbrush: Select a toothbrush with soft and rounded bristles. Change toothbrush every few months.

5. Type of toothpaste: Use the toothpaste that contains xylitol or fluoride.

6. Visit your dentist every six months for examination and cleaning even if you don't think you have any problem.  The dentist can find a hidden problem and prevent it from developing into a big problem.

7. Avoid chewing on ice, bone or another hard object as they can chip and crack your teeth and let the food trap in the rough areas.

8. The benefit of using Xylitol.  A study from the Department of Operative Dentistry from the University of Florida shown; chewing xylitol-sweetened gum three times a day, reduce caries risk in preschool children.  Xylitol suppresses Streptococcus mutans, the chief pathogen responsible for dental caries. Another study from Department of Dental Public Health Sciences at University of Washington is also supporting the anti-cariogenic properties of xylitol.

 How to floss properly:
There are two types of dental floss: waxed and non-waxed.

• The non-waxed dental floss uses in a not too tight contact between two teeth
• The waxed dental floss uses in a close contact or the contact that includes filling on the side of the tooth

Steps of proper flossing:

Cut 18 inches of floss; wind most of the floss around left middle finger

Wind the rest of dental floss around the right middle finger 

Hold dental floss with thumbs and forefingers with 1 inch apart between 2 thumbs

Insert floss between teeth with gentle saw motion

Wrapping the floss around the tooth, allow the floss to go below a gum line

Scrape the floss up and down the tooth

Advance floss after each cleaning by unwind the floss in one finger and wind the floss on the other. Continue flossing the side of all teeth.

Recent years, dental floss holders have been developed to accommodate those who want to floss while away from home.  Floss holders are available in different shapes and sizes; some are disposable, and some are refillable. Floss holders may add the convenient to flossing away from home, but the efficiency of plaque removal are less than hand-held method.

To floss the tooth with bridges, braces, implants or close contacts; use Threader Floss, which is designed to slide easily under the bridges or close contacts.

How to brush correctly:

Select a toothbrush with soft-bristled the size that fit your mouth and brush with gentle strokes.  Brush your teeth after each meal.

Front and back outer surfaces - Place brush 45 degrees angle to the gums;
move the brush sideways gently in short strokes, rotate toward chewing surfaces

Inside front teeth - place tip of the brush at the gums then rotate up toward biting surfaces

Inside back teeth - Place brush 45 degrees angle to the gums;
move the brush sideways gently in short strokes then rotate toward chewing surfaces

Chewing surfaces - Place brush on top of chewing surfaces and scrub back and forth

Reference:
Microbiology of Dental Plaque by Dr. Susan Kinder Haake
American Dental Association

Dry Socket (Alveolar Osteitis)

Characteristic of "Dry socket " or Alveolar Osteitis that occurs 2-4 days after tooth extraction are:

• A socket either wholly or partially void of blood clot
• Throbbing pain and intense pain that radiates to the front of the ear
• Erythema of the gingiva around the socket
• Putrid odor
• Other symptoms such as a headache, insomnia, and dizziness may present

 How dry socket forms

In normal condition, immediately after extraction, bleeding occurs.  Blood quickly renders and confines insoluble proteins to cover the wound. Blood clot (coagulation) forms inside a *socket and the healing process begins in steps below: 

• During the first 24 hours, a fibrin-covered clot adheres to the socket bone.  
• Within few days, fibroblasts enter the wound, this process called "Organization of the clot" and simultaneously the removal of debris (dead cell, necrotic tissue) takes place.  
• Within a week, the clot is slowly replaced by collagen fiber in granulation tissue.  
• In 10-15 days, the periphery of the socket reveals a formation of immature bone.  The amount of the immature bone increases from the base of the cavity toward the surface and from the edge of the socket to the center. 
• In approximately three weeks to six months, the mature bone replaces immature bone. 

*Note: Socket is the hollow part of the bone where the tooth roots located.

In dry socket, few days after tooth removal, a total or partial premature loss of the blood clot occurs in the socket. Direct exposure of the bone and nerve endings to the oral environment without blood clot, results in severe pain radiating toward the ear and halitosis.

Dry socket is an inflammation, not an infection; therefore, antibiotics are not indicated unless secondary bacterial infection begins at a later time.

The incidence of the dry socket has ranged from 1% to 4% of extractions; 45% occurs in mandibular third molars (lower wisdom teeth). Dry socket occurs more frequently in difficult extraction compare to routine tooth removal, according to a clinical study by Dr. Porus Turner.  In general, the healing process of dry socket takes place in 2-4 weeks.

Note:
According to the International Journal of Oral Surgery, the incidence of the dry socket may be prevented by the open surgery method. Another study by Mount Sinai Hospital, Toronto reviewed the effectiveness of the local application of clindamycin in Gelfoam reduced the incidence of dry socket formation.

Contributing factors of Dry socket:

1. Oral contraceptives increase the risk of a dry socket according to a study reporting in Journal of Canadian Dental Association. Try to schedule during the last week of the cycle, during that time the estrogen level are inactive
2. Traumatic and complicated extraction 
3. Injection of local anesthesia with vasoconstrictors as in the technique used in intraligamentous anesthesia caused insufficient supply of blood to the socket
4. Remaining of bone fragments in the socket may interfere with the healing process
5. Dry socket tends to have greater incidence after wisdom tooth extraction especially impacted teeth
6. History of dry socket after tooth extraction
7. Rinsing too soon or too vigorously; causing the clot to dislodge from the wound
8. Ignore home care instruction provided by a dentist
9. Periodontal disease or poor oral hygiene 
10. Uncontrolled diabetes
11. The use of Immunosuppressant drugs: Corticosteroids such as prednisolone (Deltasone, Orasone), Mycophenolate (CellCept), Cyclosporine (Sandimmune, Neoral), Azathioprine (Imuran) increase the incidence of dry socket
12. The recent history of Acute Ulcerative Gingivitis (Trench Mouth), Pericoronitis (infection around the crown of the tooth) associated with the extracted tooth can cause dry socket.  Therefore, appropriate antibiotic prophylaxis should be administered prior to wisdom tooth extraction.
13. Dry socket often occurs in the age group of 40-50 years old
    
14. Females are prone to have dry socket than male
15. Smoker patient has an incident of the dry socket than non-smoker according to a study reporting in Journal of Canadian Dental Association. Nicotine is a vasoconstrictor that can delay the healing process.

How to prevent dry socket

1. Before an extraction, schedule to have your teeth cleaned. The cleaning helps reduce plaque and bacteria in the oral environment
2. Use mouth rinse with 0.12% chlorhexidine gluconate just before surgery and as irrigation for at least a week after tooth extraction to reduce the risk of dry socket. (chlorhexidine gluconate mouth rinse contains chlorhexidine gluconate, alcohol, glycerin, PEG-40 Sorbitan Diisostearate, Sodium Saccharin, and FD&C Blue no.1)
3. Stop smoking prior to tooth extraction and 72 hours after tooth extraction.  The action of smoking can dislodge the clot
4. Avoid vigorous mouth rinse for the first 24 hours after tooth extraction
5. Brush your teeth gently after extraction
6. Follow the dentist instruction and see a dentist immediately if the pain increases after few days or bad taste coming out from the extracted wound
7. According to the research, women who use oral contraceptives should schedule surgery during the lowest level of estrogen, e.g., during days 23 through 28 of the tablet cycle.  The hormone can interfere with blood clotting in the socket.
8. Avoid using a straw for drinking, the suction may dislodge the blood clot in the socket
9. For women, schedule extraction during the last week of the menstrual cycle; estrogen level is lower during that time

How can you tell if you have a dry socket or how do you feel when you have the dry socket?  

Here are some of the signs and symptoms of patient who has dry socket:
 

The appearance of dry socket

1. The pain at the socket that is improving during the first few days after extraction abruptly reversing to excruciating sharp shooting pain. If the extracted tooth is in the lower jaw, the pain sometimes radiates to the ear.

2. The usual post extraction blood clot is absent from the socket

3. The bare bony socket wall is visible, sometimes a yellow-gray of necrotic tissue can be seen on the socket wall

4. Swelling of gum tissue around the socket

5. Patient may experience bad breath (Halitosis) and bad taste

6. Inability to open the mouth (Trismus). Trismus develops between 10-40 days after extraction

8. If secondary bacterial infection occurs; the regional lymph nodes on the affected side become swelling and patient begins to have fever

Note: Some patients may not experience all these symptoms.

What the dentist may do to dry socket patient

1. The dentist may irrigate a socket and remove food particles from the socket and induce bleeding leading to new blood clot formation


2. Pack the socket with a dry socket paste to relieve pain, prevent food debris from accumulate in the socket and protect the exposed bone. The dry socket paste consists of Eugenol, Guaiacol (antiseptic, anesthetic), and Chlorobutanol in anhydrous form (antibacterial and antifungal).
   
   It is necessary to change the dressing every few days (24-48 hours) for one week. The pain will improve within an hour after applying the dressing. Once the pain is tolerable, the treatment is discontinued. Prolong use of a dry socket paste may delay the healing process. Adverse reaction of Eugenol is hypersensitivity, irritation and cytotoxic when contacts with soft tissue.


3. If there are clinical signs of infection, e.g., fever, suppuration, the dentist may prescribe antibiotics
   
   
4. Instruct you to rinse your mouth gently with warm salt water (1/2 teaspoon salt in 8 ounces of very warm water) or medicated mouth rinse, e.g., 0.12% Chlorhexidine three times daily for seven days.


5. If the pain persists after 48 hours of dry socket treatment, return to the dentist for further assessment

What to do at home when dry socket occurs

Remove food debris from dry socket:

1. Use syringe with warm salt water to clean the wound
2. Gently switch your mouth with warm salt water,
3. Rinse with Listerine or 0.12% Chlorhexidine digluconate (prescribed by the dentist).

Alleviate the pain from dry socket: use Clove oil (from over-the-counter) or other products that contain oil of clove (Eugenol) such as Red Cross Toothache kits.

1. Add few drops of clove oil to cotton pellet or gauze (cut into a small size to fit the socket) and carefully apply to the wound using tweezers. To avoid burning and stinging sensation, do not allow clove oil to contact the surrounded soft tissue
    
2. Place another regular size gauze over and bite down to hold the dressing in place.
3. Change to new dressing when the dressing no longer relieves pain. This method has been successfully alleviating the pain within an hour in most cases.

Note: Due to clove oil's ability to delay the healing process, use a minimum amount necessary for the pain and stop using it as soon as pain subsides.

To care for the wound from dry socket during the first 24 hours after extraction; rinse your mouth gently with warm water after each meal.

Consume only soft food, e.g., soup.

To relieve pain with pain pills: use non-steroid anti-inflammatory drugs according to the level of pain.  See the list below:

For mild pain use:

• Acetaminophen (Paracetamol; Tylenol) 0.5 - 1g taken every 4 - 6 hours (maximum dose 4000 mg/day).  Avoid using this drug if you have liver disease or history of alcoholics.  Other name brands are:   Anacin, Dapacin, Fem-Etts, Genapap, Genebs, Mapap, Maranox, MedaCap, MedaTab, Panadol, Tapanol and some more name brands can be found here


• Ibuprofen (Advil, Motrin, Mediprin, Nurofen, Cuprofen) 200 – 400mg taken every 4 - 6 hours

For moderate pain use:

• Acetaminophen (Paracetamol, Tylenol) 0.5 - 1g + Ibuprofen 200 – 400mg taken every 4 - 6 hour. 


• Codeine + Ibuprofen 2 tablets every 8 hours (brand names include Nurofen Plus and Solpaflex)


• Codeine + Acetaminophen (Paracetamol, Tylenol) 2 tablets every 8 hours (brand names include Solpadeine, Paracodol, Solpadol, and Kapake)


• Alternating between Acetaminophen and Ibuprofen every four hours:
  
  • If you begin with 1000 mg Acetaminophen or 2 extra-strength Tylenol, after 4 hours switch to
  • 400 mg of Ibuprofen or 2 tabs of Advil. You may alternate this regimen not more than few days.
    
    Do not use this regimen if you have a history of peptic ulcer, liver disease, hypertension.  Do not take Tylenol more than 4,000 mg a day.

For severe pain

• Codeine - Acetaminophen and Ibuprofen

To relieve swelling from dry socket:

First 24 hours after extraction;
Apply an ice pack or cold towel outside of your face in the area of extraction alternately 15-20 minutes on and 15-20 minutes off for 6 hours or till bedtime.

More than 24 hours after extraction;

Apply moist heat (wet towel put in the microwave for 10-20 seconds or dip a towel in hot water) place outside of your face in the area of extraction alternately 10-15 minutes on and 10-15 minutes off.

This routine should use in all extraction.

Note: According to FDA, do not use Benzocaine topical products (gels or liquids) to numb the dry socket areas due to a severe and potentially fatal adverse effect from Methemoglobinemia.

Methemoglobinemia is a blood disorder in which an abnormal amount of methemoglobin (a type of hemoglobin that cannot carry oxygen) is produced.

In dentistry, a small amount of Benzocaine is used to lessen the pain in the area before injection in children older than two years and adults.

Signs and symptoms of Methemoglobinemia may occur within minutes up to two hours after using Benzocaine.  Call for emergency medical assistant if there are any of these symptoms:

• Rapid heart rate
• Confusion
• A light headache
• Short of breath with a pale blue or gray appearance of the skin, fingernails, and lips

Drugs in Dentistry

These are some of the drugs prescribed in dentistry.  Most dentists and physicians alike write many prescriptions without carefully weighing the benefits and risks of drugs while trying to solve the patients' problems.  Hopefully, this page may serve as a reminder of the overwhelming side effects of each drug and may slow down if not stop the writing of unnecessary prescriptions.  There are many alternative methods we can use to help our patients.  We need to think outside the box and be resourceful.

Patients should take responsibility to understand the side effects and possible interactions with their prescribed drugs.

Acetaminophen and codeine (Tylenol #3)	Diazepam (Valium)	Ibuprofen (Motrin, Advil)	TramadolHCl(Ultram, Ryzolt,Ultram ER)
Acyclovir(Zovirax) Denavir(Penciclovir)	Hydrocodone(Lorcet, Lortab,Vicodin, Norco,Zydone)	Ketorolac Tromethamine (Toradol)	Triamcinolone Acetonide(Kenalog)
Alprazolam (Xanax)	Diflunisal (Dolobid)	Methylprednisolone (Medrol)	Triazolam (Halcion)
Amoxicillin (Amoxil)	Ibuprofen (Motrin, Advil)	Metronidazole (Flagyl, Protostat)	Vicoprophen (Hydrocodone and Ibuprofen)
Azithromycin (Zithromax, Z-pack)	Erythromycin (E.E.S, Erythrocin, Ery-tab)	Nystatin cream Nystatin ointment
Chlorhexidine Gluconate(Peridex, Perioguard)	Fluconazole (Diflucan)	Penicillin VK(Penicillin V potassium)
Clindamycin (Cleocin HCL)	Hydrocodone (Lorcet, Lortab,Vicodin, Norco,Zydone)	Promethazine HCL(Promethazine Hydrochloride)

Hydrocodone

Hydrocodone (Lorcet®, Lortab,  Vicodin, Vicodin ES, Norco ®, Zydone) is in the same class as an opioid drugs for relieving of moderate to severe pain.  It is a combination of acetaminophen (Tylenol) 650 mg and Hydrocodone Bitartrate 10 mg.  Long-term used can be habit-forming.

Active ingredient: Hydrocodone Bitartrate, Acetaminophen

Inactive ingredients: colloidal silicon dioxide, pregelatinized starch, magnesium stearate, stearic acid, and croscamellose sodium povidone.

Side effects:

1. Impairment of mental and physical performance, drowsiness, anxiety, mood changes
2. Lightheadedness
3. Stomach, leg, back pains
4. Bleeding gums
5. Blood in stools or urine
6. Cough
7. Constipation
8. Breathing difficulty
9. Rapid heartbeats
10. fever
11. Swelling
12. Loss of appetite
13. Nausea or vomiting
14. Ulcers on the lips or in the mouth
15. Weakness and tiredness
16. Urinary retention, ureteral spasm
17. Respiratory depression
18. Hearing impairment or permanent loss of hearing in some cases
19. Skin rash
20. May cause respiratory depression in high dose
21. Liver failure
22. Death

Drug interactions:
Do not use Hydrocodone with patients who are taking:

• Narcotics
• Antihistamines
• Antianxiety drugs
• Alcohol

Caution:
Hydrocodone should be used with great caution in:

• Elderly
• Pregnant woman
• Patients with hypothyroidism, Addison's disease, Prostatic hypertrophy, impairment function of kidneys/liver and pulmonary disease

Maximum dose for Hydrocodone: not to exceed 40 mg on a single dose or not to exceed 80 mg on a daily dose

Hydrocodone is supplied in tablet form:
5 mg/325 mg, 7.5 mg/325 mg, 10 mg/325 mg
The first number represents the amount of Hydrocodone, and the second number represents the amount of acetaminophen.

Caution:

Before taking this pharmaceutical, consider the potential benefits and risks to other alternative options.

Kenalog

Triamcinolone Acetonide dental paste (Kenalog® in ora base) is a synthetic corticosteroid with an anti-inflammatory, antipruritic (relieve itching) action. Kenalog is used to treat mouth ulcers such as aphthous ulcer. For dental paste, drying the ulcer before applying the paste helps the Kenalog to stay in place longer.

Active ingredient in each gram contains 1 mg (0.1%) Triamcinolone Acetonide.

Inactive ingredients: Gelatin, pectin, polyethylene, mineral oil

Azithromycin (Z-pack)

Azithromycin (Zithromax Z-pack) is a pre-packaged form of a macrolide antibacterial Azithromycin (brand name; Zithromax or Zmax). Zithromax should only be used in mild to moderate infections that are strongly suspected or proven when culture information is available to be caused by susceptible bacteria, e.g., Chlamydia trachomatis. 

Macrolide antibiotic drug is a class of antibiotics that include Erythromycin, Biaxin, Clarithromycin, Ery-Tab.

Indications for Zithromax:

1. Non-gonococcal cervicitis and urethritis due to Chlamydia trachomatis
2. Prophylaxis of disseminated avian complex (MAC) disease
    in person with advanced HIV infection

Zithromax - tablet
Active ingredient is Azithromycin Dihydrate 600 mg in 1 tablet
Inactive ingredients:

• Sodium croscarmellose
• Magnesium stearate
• Dibasic calcium phosphate anhydrous
• An aqueous film coat consisting of hypromellose
• Titanium dioxide
• Lactose
• Triacetin 
• Pregelatinized starch 
• Sodium lauryl sulfate

Zithromax - Oral suspension
Active ingredient is 1 gm Azithromycin Dihydrate in a single-dose package of 5ml
Inactive ingredients:

• Colloidal silicon dioxide
  
• Sodium phosphate tribasic
• Dried artificial banana flavor
• Dried artificial cherry flavor
• Sucrose

Warning:

In March 2013, FDA issued a warning concerning a potential risk of Azithromycin (Zithromax or Zmax).  Azithromycin can cause abnormal changes in the electrical activity of the heart that may lead to a potentially fatal irregular heart rhythm. Patients who are at high risk of developing this condition include those with the conditions stated below:

• QT interval prolongation
• Low blood levels of magnesium
• Low blood levels of potassium
• Slow heart rate   
• Using certain drugs to treat abnormal heart rhythms
• Arrhythmias

On May 17, 2012, FDA released a Statement about a study that compared the risks of cardiovascular death in patients treated with the antibacterial drugs Azithromycin, Amoxicillin, Ciprofloxacin (Cipro), and Levofloxacin (Levaquin), or no antibacterial drug. 

The result of this study showed an increase in cardiovascular deaths and in the risk of death in patients treated with a 5-day course of Azithromycin (Zithromax) and Levofloxacin compared to persons treated with Amoxicillin, Ciprofloxacin, or no drug.

Side effects reported in adults and pediatric patients include:

1. Angioedema (deep skin layer hives-liked)
2. Arthralgia (joint pain)
3. Cholestatic jaundice
4. Nausea, vomiting, diarrhea
5. Abdominal pain
6. Chest pain
7. Palpitation (irregular/forceful beating of the heart)
8. Dyspepsia (indigestion)
9. Flatulence (excessive gas in the intestinal tract)
10. Melena (stool or vomit that is black due to blood pigment)
11. Vaginitis
12. Nephritis (inflammation of the kidney)
13. Dizziness, headache, vertigo, convulsion
14. Semnolence (sleepiness)
15. Rash
16. Photosensitivity
17. Arthralgia (joint pain)
18. Urticaria (hives)
19. Arrhythmias
20. Tachycardia (rapid heart rate greater than 100 beats)
21. Hypotension
22. Anorexia (an eating disorder, markedly reduce appetite
23. Constipation
24. Pseudomembranous colitis (severe inflammation of the inner lining of the colon)
25. Pancreatitis
26. Oral candidiasis
27. Pyloric stenosis (narrowing passage between the stomach and duodenum)
28. Tongue discoloration
29. Asthenia (weakness, lack of energy and strength)
30. Paresthesia (numbness, tingling, burning sensation)
31. Anaphylaxis (allergic reaction)
32. Thrombocytopenia (low platelets count)
33. Hepatic necrosis (death of liver cells or tissues)
34. Hepatic failure
35. Nervousness, agitation
36. Syncope (partial or complete loss of consciousness)
37. Anxiety and aggressive reaction
38. Pruritus (itching)
39. Erythema multiforme
40. Stevens-Johnson syndrome
41. Toxic epidermal necrolysis
42. Hearing loss, deafness, tinnitus

Caution:

Before taking this pharmaceutical, consider the potential benefits and risks to other alternative options.

Alprazolam (Xanax®)

Alprazolam Xanax® is a medication used for the management of a short-term relief of the anxiety associated with stress and panic disorder. Dosage initiated with a dose of 0.25 to 0.5 mg/3 times a day, not to exceed 4 mg per day in divided doses.

Active ingredient in a tablet contains 0.25,0.5,or 2 mg of Alprazolam

Inactive ingredients: Corn starch, Cellulose, docusate sodium, lactose, magnesium stearate, silicon dioxide, benzoate and dyes.

Side effect:

1. Drowsiness
2. Lightheadedness        
   
3. Depression
4. Confusion
5. Nervousness
6. Syncope
7. Dizziness
8. Akathisia (restlessness)
9. Dry mouth
10. Constipation
11. Diarrhea
12. Nausea, vomiting
13. Tachycardia
14. Palpitation
15. Hypotension
16. Blurred vision
17. Tremor
18. Nasal congestion
19. Weight gain/weight loss
20. Impaired coordination
21. Irritability
22. Memory impairment
23. Insomnia
24. Dysarthria (stuttering)
25. Anxiety
26. Decreased libido
27. Involuntary movement
28. Weakness
29. Syncope
30. Paresthesia (an abnormal sensation as itching, prickling)
31. Upper respiratory infection
32. Tinnitus (ringing sound in the ears)
33. Muscle cramps
34. Rash
35. Sweating
36. Edema
37. Incontinence (unintentional loss of urine) 
38. Edema
39. Menstrual disorders
40. Seizure
41. Hallucination
42. Diplopia (double vision)
43. jaundice

Caution:

Before taking this pharmaceutical, consider the potential benefits and risks to other alternative options.

Vicoprofen

Vicoprofen ( Hydrocodone and Ibuprofen) is an opioid with an analgesic, antipyretic and nonsteroidal anti-inflammatory properties for short-term (less than 10 days) treatment of acute pain. The recommended dose is 1 tablet every 4-6 hours, not to exceed 5 tablets in 24 hours.

Active ingredients are Hydrocodone Bitartrate 7.5 mg and Ibuprofen 200 mg.

Inactive ingredients include colloidal silicon dioxide, corn starch, croscamellose sodium, hypromellose,  microcrystalline cellulose, magnesium stearate, polyethylene glycol, dioxide, and polysorbate80.

Side effects:

1. Abdominal pain, ulcers and bleeding in  and intestine
2. stomach
3. Heart palpitation
4. Anxiety
5. Confusion
6. Insomnia
7. Dizziness
8. Nervousness
9. Paresthesia
10. Somnolence (sleepiness, drowsiness)
11. Anorexia (reduced appetite)
12. Constipation
13. Diarrhea
14. Dry mouth
15. Dyspepsia (indigestion)
16. Pharyngitis
17. Rhinitis (irritation of the nose)
18. Pruritus (itching)
19. Sweating
20. Tinnitus (ringing sound in the ears)
21. Arrhythmia (an abnormal heart rhythm)
22. Tachycardia (rapid heart rate, greater than 100 beats/minute)
23. High blood pressure
24. Weight loss
25. Dysphagia (difficulty swallowing)
26. Gastroenteritis (inflammation of the stomach and the intestines)
27. Joint pain
28. Muscles pain
29. Urticaria (hives)
30. Rash
31. Altered vision
32. Bad taste
33. Dry eyes
34. Cystitis (inflammation of the bladder)
35. Urinary incontinence (unintentional loss of urine)
36. Pneumonia
37. Decreased libido
38. Depression
39. Euphoria (elevated mood)
40. Neuralgia
41. Tremor
42. Vertigo
43. Slurred speech
44. Asthma, Bronchitis, cough, sinusitis
45. Heart attack
46. Stroke
47. Kidney failure
48. Liver failure
49. Life-threatening allergic reactions

Caution:

Before taking this pharmaceutical, consider the potential benefits and risks to other alternative options.

Diazepam (Valium)

Diazepam (Valium) is a medication used for a short term relief of anxiety during a dental visit.  Prolong use of Valium may lead to physical dependence.

Active ingredient: Diazepam

Inactive ingredients: corn starch, anhydrous lactose, pregelatinized starch, calcium stearate, dyes (all Valium has dye except 2 mg tablet contains no dye)

Valium is available in 2 mg, 5mg or 10 mg. Dispense 2 tabs, bring prescription to appointment, do not take before appointment

Contra-indications:
Do not use this medication if you are pregnant or have:

• Glaucoma
• Myasthenia gravis
• Sleep apnea

Side effect:

1. Confusion
2. Depression
3. Dysarthria (slurred, slow speech)
4. Vertigo (things are dizzily turning around you)
5. Headache
6. Tremor (bodily shaken uncontrollable)
7. Constipation
8. Nausea
9. Diplopia (double vision)
10. Hypotension
11. Stimulation, restlessness, anxiety, agitation, rage, hallucination
12. Muscle spasm
13. Insomnia
14. Nightmares
15. Incontinence (inability to control excretion)
16. Changes in libido
17. Urinary retention
18. Dry mouth
19. Jaundice
20. Antegrade amnesia (inability to recall new information)

Caution:

Before taking this pharmaceutical, consider the potential benefits and risks to other alternative options.

Tylenol® #3

Acetaminophen and codeine combination (Tylenol #3) is a drug used to relieve moderate to severe pain.  Tylenol #3 is in a narcotic class and should not be taken in a large amount or for a longer period than prescribed due to its potential habit forming. Tylenol #3 should be taken with food to prevent upset stomach.

Caution must be taken when prescribe to elderly patients, patients with head injuries, severe kidney or liver disease, hypothyroidism, Addison's disease and acute abdominal problems. Do not prescribe to children under 12 years of age. Prolong use of Tylenol #3 results in tolerance to codeine. During pregnancy, Tylenol with Codeine should not be used close to the expected delivery date and should not be used during nursing.

The usual adult dosage of Tylenol with codeine is 15 mg to 60 mg codeine and 300 to 1000 mg acetaminophen every 4 hours.  Codeine higher than 60 mg may increase undesirable side effects.

Active ingredients in a tablet contain Acetaminophen 300 mg, Codeine Phosphate 30 mg.
Inactive ingredients: Powder cellulose,  Magnesium stearate, Sodium metabisulfite, Pregelatinized corn starch and modified corn starch.

Side effects:

1. Nausea, vomiting
2. Constipation
3. Lightheadedness, fainting
4. Dizziness or drowsiness
5. Difficulty breathing, shallow breathing or irregular breathing
6. Allergic reactions
7. Elevated mood (Euphoria)
8. Anxiety (Dysphoria)
9. Abdominal pain
10. Itching (Pruritus)
11. Rash
12. Low platelet count (Thrombocytopenia)
13. Decrease in white blood cell granulocytes (Agranulocytosis)
14. Respiratory depression (on high dose)
15. Pale, blue lips, fingernails
16. Seizures
17. Black stool
18. Easy bruising or bleeding
19. Blood found in urine
20. Swelling at the lips, eyelids, face, or tongue
21. Blurred vision
22. Dry mouth

Caution:

Before taking this pharmaceutical, consider the potential benefits and risks to other alternative options.

Tramadol HCl (Ultram®)

Tramadol HCl (Ultram®)
Tramadol HCl extended-release (Ultram ER, Ryzolt)

Tramadol HCl is a narcotic-like pain reliever for moderate to moderately severe pain, addiction may occur in some patients especially those who have abused alcohol or drug in the past.  Tramadol is not a NSAID (nonsteroidal anti-inflammatory drug), therefore, it does not increase the risk of stomach ulceration.  The maximum dose is 400 mg/day, the maximum dose for older than 75 years is 300mg/day.

Dispense:
For immediate release tablets; 50-100 mg  every 4-6 hours as needed for pain. 

For extended-release tablets;  100 mg per day, not to exceed 300 mg per day.

Preparations of Tramadol HCl:

• Tablet, 50 mg for immediate release (Ultram®)
• Tablet, 100, 200, 300 mg for extended release (Ryzolt)
• Capsule, 100, 200, 300 mg for extended release (Ultram ER)

Tramadol HCl may cause withdrawal reaction, e.g., eyes watering, nausea, sweating, muscle pain, restlessness, if suddenly stop the medication especially in a long time or high doses users. To prevent the withdrawal effects, reduce the dose gradually.

Side effects:

1. Dizziness, vertigo
2. Nausea
3. Constipation, upset stomach
4. Headache
5. Sleepy (Somnolence), drowsiness
6. Vomiting
7. Itching (Pruritus)
8. Nervous, anxious
9. Agitation
10. Anxiety
11. Tremor
12. Spasticity (exhibiting spasm)
13. Euphoria (elevated mood)
14. Hallucination
15. Weakness (Asthenia)
16. Sweating (Diaphoresis)
17. Indigestion (Dyspepsia)
18. Dry mouth
19. Diarrhea
20. Vague feeling of discomfort (Malaise)
21. Widening of blood vessels (Vasodilation)
22. Confusion
23. Contraction of the pupil (Miosis)
24. Coordination disturbance
25. Sleep disorder
26. Abdominal pain
27. Eating disorder (Anorexia)
28. Flatulence (excessive gas in the intestinal tract)
29. Increase tightness of muscle tone and reduce muscle capacity to stretch (Hypertonia)
30. A red, blistering, skin rash
31. Visual disturbance
32. Urinary retention, urinary frequency
33. Menopausal symptoms
34. Allergic reaction (Swelling of the face, lips, tongue, lips or throat)
35. Anaphylaxis
36. Suicidal tendency
37. Death
38. Weight loss 
39. Increase serotonin
40. Serotonin syndrome (over reflexes, shivering, fever, tremor, agitation, sweating, seizures and coma)
41. Orthostatic hypotension
42. Partial or complete loss of conscious (Syncope)
43. Rapid heart rate greater than 100 beats/minute (Tachycardia)
44. Amnesia
45. Depression
46. Paresthesia
47. Seizures
48. Shortness of breath (Dyspnea)
49. Stevens-Johnson syndrome (severe eruption of the skin and mucous membrane due to inflammation from an allergic reaction to drugs or substances)
50. Loss sense of taste (Dysgeusia)
51. Pain or difficulty urinating (Dysuria)
52. Menstrual disorder
53. Hypertension, hypotension
54. Palpitation
55. Pulmonary edema, pulmonary embolism
56. Myocardial ischemia
57. Migraine
58. Speech disorder
59. Gastrointestinal bleeding
60. Hepatitis
61. Stomatitis
62. Liver failure
63. Proteinuria
64. Tinnitus, deafness

Drug interactions:

1. When combine Tramadol HCl with one of these drugs:

• Quinidine, 
• Fluoxetine, 
• Paroxetine, 
• Amitriptyline, 
• Ketoconazole 
• Erythromycin, 

The combination may reduce metabolic clearance of tramadol HCl, and increase the risk of serious adverse reaction such as Serotonin syndrome and seizures.

2. When combine Tramadol HCl with any of these drugs:

• Antidepressant SSRIs and SNRIs
• Monoamine oxidase inhibitors (MAOIs)
• Triptans
• Linezolid
• Lithium
• St.John's wart 

This combination affects the serotonergic neurotransmitter system. Physicians and dentists must carefully observe for sign of Serotonin syndrome at the initial dose and increased dose of Tramadol HCl.

3. When combine Tramadol HCl with an anticonvulsant and mood- stabilizing Carbamazepine (Tegretol, Equetro), drug used primarily for treatment of epilepsy, bipolar disorder and trigeminal neuralgia, this combination may reduce analgesic effect of Tramadol HCl by increasing metabolism of Tramadol HCl.  Because of the seizures risk associated with Tramadol HCl, co-administer of Tramadol HCl and Carbamazepine is not recommended.

4. When combine Tramadol HCl with Quinidine (Quinidine gluconate, Quinidine sulfate), an antiarrhythmic drug, this combination may increase Tramadol HCl concentration.  The clinical consequence is unknown.

5. In a rare event, the combination administration of Tramadol HCl with Digoxin and Warfarin may result in Digoxin toxicity and elevation of prothrombin times.

Caution:

Before taking this pharmaceutical, consider the potential benefits and risks to other alternative options.

Promethazine HCl

Promethazine Hydrochloride is an anti-histamine that is used to treat:

• Certain types of allergy
• Antiemetic (anti-nausea and vomiting)
• Sedation before surgery and relief of apprehension in both children (older than 2 years) and adults

Promethazine competes with the naturally occurring histamine in the cell receptor level, thus prevent naturally occurring histamine from binding to the cell receptor. When naturally occurring histamine cannot bind to the cell receptor to stimulate changes within the cells, no allergic symptoms can occur.

Active ingredient in Promethazine tablet contains 25 mg or 50 mg of Promethazine HCL
Inactive ingredients: Magnesium stearate, Dibasic calcium phosphate, Microcrystalline cellulose, Stearic acid, Sodium starch glycolate (in 50 mg tablet also contains Anhydrous lactose)

Drug interactions
1. Promethazine hydrochloride may increase, prolong, intensify the action of sedative/hypnotics, narcotic analgesics, anti-depressant medications. Therefore, either avoid or reduced dose of promethazine HCl when given concomitantly with the above medications.

2. Do not use epinephrine to treat hypotension associated with Promethazine HCl overdose because Promethazine has ability to reverse the vasopressor effect of epinephrine.

3. Promethazine hydrochloride taken with anticholinergic medications may increase extrapyramidal effects.

4. Promethazine hydrochloride with a pregnancy test may result in false-negative or false-positive interpretations

5. Promethazine hydrochloride may increase blood glucose in Glucose Tolerance Test result in false interpretation.

To avoid complications with Promethazine hydrochloride, report to your physicians, dentist if you are taking medications for:

• Cold allergy
• Sedatives
• Narcotics
• Sleeping
• Muscle relaxants
• Seizures
• Depression
• Anxiety
• Depression
• Blood thinners
• Bladder or urinary
• Stomach ulcer
• Parkinson's
• Pituitary gland tumor
• Restless leg syndrome

Side effects:

1. Drowsiness, dizziness
2. Fatigue
3. Ringing in the ears
4. Blurred vision
5. Nervous
6. Tremor
7. Insomnia
8. Rash, dermatitis
9. Itching
10. Dry mouth, nausea, vomiting
11. Trouble with walking, balancing and coordination
12. Feeling agitated, restless
13. Severe confusion (Delirium)
14. Hallucination
15. Euphoria (mood changing)
16. Double vision (Diplopia)
17. Seizures
18. Hysteria
19. Increased or decreased blood pressure
20. Fainting
21. Rapid heart rate, greater than 100 (Tachycardia)
22. Slow heart rate, less than 60 beats per minute (Bradycardia)
23. Low white blood cells
24. Jaundice
25. Neuroleptic malignant syndrome
26. Respiratory depression
27. nightmares

Caution:

Before taking this pharmaceutical, consider the potential benefits and risks to other alternative options.

Chlorhexidine Gluconate (Peridex)

Chlorhexidine Gluconate (Peridex, periogard) 0.12% is an antimicrobial mouth rinse used between visits during gum treatment for gingivitis. Chlorhexidine Gluconate helps reduce the amount of both aerobic and anaerobic bacteria in the oral cavity.

Active ingredient in Peridex contains 0.12% Chlorhexidine gluconate

Inactive ingredients: Water, Alcohol, Glycerin, PEG-40 Sorbitan diisostearate,  Sodium saccharin and Dye.

Dispense 
Peridex 0.12 % oral rinse (118 ml, 473 ml) 1 bottle, use 1 Tbsp to rinse for 30 second after brushing in the morning and evening and expectorate after rinsing.  Do not rinse with water, other mouthwashes, brush teeth or eat immediately after using Peridex.

Side effects:

1. Staining teeth
2. Increase calculus formation
3. Taste alteration
4. Oral irritation:
• Aphthous ulcer
• Gingivitis
• Trauma
• Ulceration
• Erythema
• Coated tongue                              
• Geographic tongue
• Mucocele
• Stomatitis
• Dry mouth
• Glossal edema
• Paresthesia
• Desquamation of the oral mucosa
• Swelling of the salivary glands

Nystatin cream

Nystatin cream or Nystatin ointment is an antifungal (yeast) medication that is derived from Streptomyces Noursei.  Nystatin is used for fungus infection in the skin, esophagus, mouth and vagina that caused by candida albicans.

In healthy person, yeast and beneficial bacteria are living in balance in the digestive tract system, with an almost undetectable amount of yeast versus an overwhelm amount of beneficial bacteria.  When this balance changes, the beneficial bacterial level is low, yeast begins to spread.  An overgrowth of yeast caused variety of fungal diseases.

Nystatin cream
Active ingredient contains 100,000 USP Nystatin units per gram.
Inactive ingredients: Emulsifying wax, Isopropyl  myristate, Glycerin, Lactic acid, Sodium hydroxide and Sorbic acid

Nystatin ointment
Active ingredient contains 100,000 USP Nystatin units per gram
Inactive ingredients: Light mineral oil and white petrolatum

Side effects of Nystatin:

1. Allergic reaction (hives, difficulty breathing, swelling of the face, tongue, lips and throat)
2. Itching
3. Irritation

Dispense:
Nystatin Cream 15 grams, apply to affected area 3 times a day.

Methylprednisolone (Medrol®)

Methylprednisolone (Medrol®) is an anti-inflammatory steroid that used to treat inflammatory conditions such as:

• Arthritis, 
• Systemic lupus erythematosus, 
• Psoriasis, Severe Erythema multiforme, 
• Stevens-Johnson syndrome, 
• Severe allergy, 
• Ulcerative colitis, 
• Leukemia, 
• Anemia, 
• Some ophthalmic diseases, 
• Thyroiditis, 
• Adrenal hyperplasia.

In dentistry, Medrol® is used for controlling inflammation after oral surgery.  Long-term used of Medrol may cause a withdrawal effect.

Medrol® is prescribed in dose pack in 4 mg tablets, sometimes refer to as Methylprednisolone Dose Pack or Medrol Dose Pack.

Active ingredient in each tablet of Medrol contains 2mg, 4 mg, 8 mg, 16 mg, 32 mg of Methylprednisolone.

Inactive ingredients:

• Calcium stearate
• Corn starch
• Erythrosine sodium
• Mineral oil
• Lactose
• Sucrose
• Sorbic acid
• Dye ( 8 mg and 32 mg)

Medrol® side effects:

1. Nausea, vomiting
2. Swelling, weight gain
3. High blood pressure 
4. Congestive heart failure
5. Headache, vertigo, convulsion
6. Osteoporosis
7. Anxiety
8. Dizziness
9. Loss appetite
10. Trouble sleeping
11. Confusion
12. Shortness of breath
13. Chest pain
14. Seizure
15. Peptic ulcers (possible bleeding or perforation)
16. Severe depression
17. Blood coming out from stools or coughing
18. Pancreatitis  (rapid heart rate, pain in the upper stomach, nausea, vomiting)
19. Low potassium (confusion, palpitation, increased urination, extreme thirst, muscle weakness)
20. Insomnia, mood changes
21. Skin problems (petechiae, dry skin, discoloration due to bruise)
22. Increase sweating, facial skin redness
23. Menstrual irregularities
24. Blood sugar may rise, cause Diabetes mellitus or worsen diabetes
25. Lower the body the ability to fight infections
26. Glaucoma, cataracts
27. Bloating
28. Steroid medication can weaken the immunity, makes the body prone to infection or worsen the infection that you already have.

Caution:

Before taking this pharmaceutical, consider the potential benefits and risks to other alternative options.

Ketorolac Tromethamine (Toradol)

Toradol is not available in U.S, but the generic brand may still be available.  Ketorolac Tromethamine is in a member of nonsteroidal anti-inflammatory drugs (NSAIDs) indicated for severe acute pain in adults up to five days as a continuation therapy to IV or IM dosing. To minimize the potential risk for adverse reaction, use the lowest effective dose with the shortest duration.

When not to use (contraindication) Ketorolac Tromethamine:

1. Do not use Ketorolac Tromethamine oral formulation as an initial dose
2. Patients with heart disease
3. Do not use in patients younger than 17 years
4. Mild or chronic pain
5. Patients with peptic ulcers or history of peptic ulcers and gastrointestinal bleeding  
6. Patients with recent gastrointestinal bleeding or perforation
7. Patients with renal impairment or at risk of renal failure
8. Nursing mother
9. Do not prescribe to patients who are currently taking aspirin or NSAIDs
10. Do not use Ketorolac Tromethamine during labor or delivery due to the effect on fetus circulation
11. As a prophylactic analgesic before surgery
12. Suspected or confirmed Patient with cerebrovascular bleeding
13. Pain reliever after coronary artery bypass graft (CABG) surgery
14. Do not use Ketorolac Tromethamine more than five days
15. Do not exceed daily maximum dose of 40 mg

Active ingredient in a tablet contains 10 mg Ketorolac Tromethamine
Inactive ingredients:

• Lactose, Magnesium stearate
• Microcrystalline cellulose
• Hydroxypropyl methylcellulose
  
• Polyethylene glycol
• Titanium dioxide

Drug interactions: Patients should not take Ketorolac Tromethamine with the following medications:

• Aspirin
• Diuretics, e.g., Furosemide, Thiazides
• Probenecid
• Lithium
• Metrotrexate
• Angiotensin receptor blockers or ACE inhibitors (drugs for treatment of the kidney damaged due to diabetes, high blood pressure, congestive heart failure)
• Antiepileptic drugs (Ketorolac tromethamine, Phenytoin, Carbamazepine)
• Psychoactive drugs (Fluoxetine, Thiothixene, Alprazolam
• Pentoxifylline

Side effect:

1. Abdominal pain, Gastric and duodenal ulcers
2. Tachycardia, syncope, hypotension, chest pain, myocardial infarction
3. Stool is black or bloody
4. Cough up blood
5. Ecchymosis (skin discoloration as in a bruise)
6. Swelling (Angioedema), rapid weight gain
7. Mouth sores
8. Constipation/diarrhea
9. Flatulence (excessive gas)
10. Nausea, vomiting, sweating
11. Abnormal renal function
12. Drowsiness, vertigo
13. Headaches, fever, sore throat
14. Anemia
15. Laryngeal edema, tongue edema
16. Hypertension
17. Itching (Pruritus)
18. Ringing in the ears (Tinnitus)
19. Increased bleeding time 
20. Fever, sepsis
21. Congestive heart failure
22. Palpitation
23. Photosensitivity (sensitivity to light)
24. Urticaria (itchy red or white raised patch on the skin)
25. Anorexia (loss of appetite, inability to eat)
26. Dry mouth
27. Jaundice
28. Insomnia (difficulty in falling or staying asleep)
29. Malaise
30. Paresthesia
31. blurred vision
32. Increased urinary frequency
33. Aseptic meningitis
34. Convulsions, coma, psychosis
35. Respiratory depression, pneumonia

Caution:

Before taking this pharmaceutical, consider the potential benefits and risks to other alternative options.

Ibuprofen (Motrin®, Advil)

Ibuprofen (Motrin®, Advil) is a non-steroid, non-narcotic analgesic, anti-inflammatory and antipyretic drug (NSAID). Ibuprofen is used to reduce fever, relieve mild to moderate pain and inflammation caused by toothache, back pain, arthritis, menstrual cramp.

Active ingredient is Ibuprofen.

Inactive ingredients are propylene glycol, titanium dioxide, carnauba wax, colloidal silicon dioxide, croscarmellose sodium, hypromellose, lactose, magnesium stearate, microcrystalline cellulose.

Dispense:

Ibuprofen should be taken with food or milk to lessen the stomach irritation.  Maximum amount for an adult is 800 mg per dose every 4-6 hours, not to exceed 3200 mg per day

Ibuprofen chewable tablet (50 mg) must be chewed before swallowing.

Side effects:

1. Heartburn
2. Nausea and vomiting 
3. Diarrhea
4. Constipation
5. Indigestion
6. Bloating and flatulence
7. Gastric or duodenal ulcer with bleeding or perforation
8. Dizziness, headache, nervousness
9. Numbness, tingling, burning sensation (Paresthesia)
10. Hallucinations
11. Insomnia, depression, confusion
12. Meningitis
13. Ringing in the ears (Tinnitus)
14. Anemia
15. Loss appetite
16. Edema, fluid retention
17. Palpitation
18. Elevated blood pressure
19. Acute renal failure
20. Dry eyes and mouth, gingival ulcer

Contraindications:

• Patient should not take Ibuprofen after coronary artery bypass graft surgery
• Do not use NSAIDS with patients who have cardiovascular disease due to the increasing risk of myocardial infarction and stroke.

Drug interactions:

• Patient should not take Aspirin with Ibuprofen due to the potential adverse reaction increased 
• Ibuprofen can reduce the effectiveness of Furosemide and Thiazides in some patients
• Lithium taken with Ibuprofen may reduce renal Lithium clearance causing Lithium toxicity
• Methotrexate taken with Ibuprofen may enhance the toxicity of Methotrexate
• Warfarin-type anticoagulants taken with Ibuprofen may increase GI bleeding

Note:  
Carefully consider the potential risks and benefits of this pharmaceutical to other alternative options before using it.

Triazolam (Halcion®)

Triazolam (Halcion®) is a hypnotic agent.  It is indicated for the short-term treatment of insomnia (7-10 days).

Active ingredient is Triazolam

Inactive ingredients are cellulose, corn starch, docusate sodium, lactose, magnesium stearate, silicon dioxide, sodium benzoate, FD&C blue no.2 (in 0.25 mg)

Dispense:
The recommended dose for adult is 0.25 mg taken one hour before the appointment.  A dose of 0.125 may be sufficient in patient with low body weight.

Side effects:

1. Drowsiness, dizziness, lightheadedness
2. Nausea, vomiting
3. Tiredness
4. Elevated mood (Euphoria)
5. Rapid heart rate (greater than 100 beats per minute) (Tachycardia)
6. Memory impairment, confusion
7. Taste alterations, dry mouth
8. Insomnia, dreaming, nightmares
9. Numbness, tingling, burning sensation (Paresthesia)
10. Ringing in the ears (Tinnitus)
11. Weakness, fatigue
12. congestion
13. Hepatic failure and death
14. Amnesia
15. Slurred speech (Dysarthria)
16. Jaundice
17. Twisting body motions (Dystonia)
18. Eating disorder (Anorexia)
19. Itching (Pruritus)
20. Changes in libido
21. Urinary retention
22. Sleep disturbance

Caution:

Before taking this pharmaceutical, consider the potential benefits and risks to other alternative options.