Vu Orthodontics - Orthodontics, Periodontics, and Implants

Dosage and Instructions

Major dental surgeries include extracting impacted wisdom teeth (3rd molars), socket graft (for ridge preservation), GBR (Guided Bone Regeneration), horizontal or vertical ridge augmentation or both, sinus lift, GTR (Guided Tissue Regeneration, hard and soft tissues), and dental implants. The author routinely does bone graft for every tooth extraction if ridge preservation is needed. In the extraction case of mandibular 3rd molars, a bone graft is necessary to prevent bony defect distal to the 2nd molars. A study in the literature indicates that this type of bony defect more likely occurs with patients who are older than about 26 years old.

Disclaimer. To prevent possible infection associated with these procedures, especially with bone graft and implants, a brief discussion of medications (for adult patients) is presented here. But the author is not responsible for any foreseeable or unforeseeable adverse reactions or consequences. People must consult with their medical specialists.

1. Antibiotics (must): Amoxicillin, 500 mg, 1 PO (by mouth) 3x/d (t.i.d., or every 8 hr), for 7 days, then consult the dentist. The capsule may be taken either before or after a meal. (Amoxicillin belongs to the penicillin family.)

Note that the "loading dose" (just before surgery) is double the "maintenance dose." For example,  with amoxicillin, 1,000 mg is the loading dose, whereas 500 mg is the maintenance dose.

Alternatives

1) Some dentists recommended Augmentin (amoxicillin / clavulanate) which is an antibiotic medication combining amoxicillin and clavulanate potassium because Augmentin is more potent than amoxicillin alone, generally. Economically, Augmentin approximately costs twice as much compared to amoxicillin. If amoxicillin is either sufficient or adequate, then the use of Augmentin is an "economic waste." Further, Augmentin has a higher risk of diarrhea and liver damage compared to amoxicillin alone.

2) If the adult patient is allergic to penicillin, then clindamycin is an alternative.  Recommended dosage: 300 mg, 4x/d (q.i.d, or every 6 hr), for 7 days. The capsule may be taken either before or after a meal. (Source: Actavis. Package leaflet: Information for the patient)

Warning: Some pharmarcist has reported that the major side effect of clindamycin is diarrhea (i.e., severe diarrhea). Thus, it is recommended that clindamycin should not be used more than one week, for fear of Pseudomembranous colitis.

Pseudomembranous colitis, also called antibiotic-associated colitis or C. difficile colitis, is inflammation of the colon associated with an overgrowth of the bacterium Clostridioides difficile (formerly Clostridium difficile) — often called C. diff.

Reducing the dose of clindamycin from 600 mg to 300 mg would reduce the risk of having the side effect of diarrhea.

3) An alternative of clindamycin is azithromycin. 

4) For chronic infection, metronidazole (Flagyl, Metrogel, Noritate) is also recommended to be used (in addition), 500 mg, 1 PO (by mouth) 3x/d (t.i.d.) or every 8 hr, for 7 days, then consult the dentist. Its dose and usage are the same as with amoxicillin, for convenience. 

Metronidazole is excellent for controlling anaerobes but not aerobic and facultative anaerobic bacteria. If metronidazole is prescribed, the patient must be warned about not consuming any alcohol which may cause a number of unpleasant side effects, including headaches, stomach cramps, nausea, vomiting, flushing, and irregular heartbeat.

2. Pain control (if needed, PRN): 

a) Ibuprofen (Advil, Motrin), 600 mg, 1 PO every 4-6 hr PRN (abbreviated for the Latin term, "pro re nata" which translates to "as needed").  Though not absolute, the conveniently recommended maximum dose for ibuprofen is 3,000 mg per 24 hr (since 600 mg x 5 = 3,000 mg), to avoid toxicity to the kidneys.

The highest dose of ibuprofen is 800 mg which should be avoided to prevent overdose.

The OTC (over the counter) dose of ibuprofen is 200 mg.  Thus, 3 pills of 200 mg equal 600 mg. 

The medication must be taken with food to avoid stomach upset or reduce the risk of side effects. Note that ibuprofen has a weak anti-inflammatory property.

People with the following conditions should not take ibuprofen: allergies, Stevens-Johnson syndrome, pregnant women, fluid retention resulting from cardiovacular disease, bleeding disorders, bipolar disorder, obsessive-composive disorder, etc. (Source: Dr. Tom Viola, Dentistry iQ)

Warning: Do not take ibuprofen just before or right after surgery because it would cause bleeding. 

b) Tylenol Extra Strength (500 mg), 1 PO every 4-6 hr PRN. Tylenol may be taken with or without food. It is not absolute, but the recommended maximum dose for Tylenol is 3,000 mg per 24 hr, to avoid toxicity to the liver.

Notes:

Tylenol is processed by the liver, whereas ibuprofen is processed by the kidneys.

In theory, taking a combination of Tylenol and ibuprofen may be even more potent than Tylenol-Codeine #3 (narcotic).  Thus, there may be no need for dentists to prescibe any control substance such as Tylenol-Codeine #3.

However, in real life, some patients experience that ibuprofen is effective in controlling their pain, whereas Tylenol is not.

3. Anti-inflammation (should): For certain major surgeries, significant swelling may occur to some patients, and typically peaks at 24–48 h postop.  Swelling is generally caused by inflammation, and inflammation causes bone loss, inter alia (among other things.)  Therefore, anti-inflammation medication should be used to prevent bone loss.

Short-term use of steroid drugs -- for a few days or less than a week -- is safe. As an alternative, some clinicians recommend using an ice pack for control of swelling.

The adrenal glands produce cortisol, a vital steroid hormone involved in metabolism, immune response, and stress regulation. Steroid drugs, especially glucocorticoids, mimic cortisol's effects. When synthetic steroids are taken, particularly over prolonged periods (more than a few weeks), they suppress the body's natural production of cortisol by exerting negative feedback on the hypothalamic-pituitary-adrenal (HPA) axis.

The author uses a simple prescription for dexamethasone in the context of a major dental surgery, such as GTR (Guided Tissue Regeration), or GBR (Guided Bone Regeneration), or extraction -- assuming an adult patient with no contraindications.

Medication: Dexamethasone 4 mg tablets
Sig: Take 2 tablets (8 mg) by mouth 1 hour before surgery, then take 1 tablet (4 mg) once daily for 2 days after surgery, and then consult the dentist. Dexamethasone should be taken with food (or immediately after a meal)

Alternative:

Dexamethasone, 4 mg, 1 PO (oral, aka "by mouth"), daily (1x/d  or q.d.), with food (to avoid stomach upset), for 2-3 days,

✅ Rationale:

8 mg pre-op provides a strong anti-inflammatory loading dose.

4 mg for 2 days gives coverage during peak swelling (typically 24–48 h postop) without prolonged steroid exposure.

No taper needed because of short duration.

Some clinicians prefer to prescribe Prednisone or Medrol Pak.

Prednisone and dexamethasone are both corticosteroids used to reduce inflammation and suppress the immune system, but they differ notably in potency, duration of action, and usage scenarios. Dexamethasone is approximately 6 times more potent than prednisone and has a much longer half-life (36 to 72 hours) compared to prednisone’s shorter half-life of 3 to 4 hours. This means dexamethasone acts longer in the body, allowing for shorter treatment courses.

Clinically, dexamethasone is often preferred when a stronger, longer-acting steroid effect is needed, such as in certain severe inflammatory conditions or when quick onset and sustained action are desired. Prednisone, being intermediate-acting, is typically used when a shorter duration of steroid action is appropriate or when more gradual tapering (more complicated for patients) is required.

Medication: Medrol Pak (more complicated)

Active Ingredient: methylprednisolone

Brand Name: Medrol

ROA (route of administration): Oral

Inactive Ingredients: calcium stearate, cornstarch, lactose, sucrose

Medrol Pak (oral): tapered-dose pack (21 pills of 4 mg ea.), in a single dose or divided doses (breakfast, lunch, dinner):

Day 1: 6 pills of 4 mg ea.

Day 2: 5 pills of 4 mg ea.

Day 3: 4 pills of4 mg ea.

Day 4: 3 pills of 4 mg ea.

Day 5: 2 pills of 4 mg ea.

Day 6: 1 pill of 4 mg

Some patients may have a concern with taking Prednisone or methylprednisolone since they are steroids.  In general, using either one of these two steroids together with ibuprofen may increase the risk of side effects in the gastrointestinal (GI) tract.  These side effects include inflammation, bleeding, and ulceration. Though unlikely, GI perforation might also occur, which is a serious medical emergency.  But, again, the short-term use of Prednisone or methylprednisolone is harmless.

Warning: People should not take Prednisone or methylprednisolone if they have bleeding disorders.

4. Mouth rinse (optional): to prevent infection on the surface of the surgical site): chlorhexidine (CHX or Peridex generic, 0.12%), 2x/d (b.i.d) or every 12 hr. Swish-then-spit CHX for 30 s, and then spit it out.  Do not rinse, drink, or eat, for about half-an-hour. Use it about 24 hr after the surgery. Note that CHX does kill fibroblasts, but the advantage may outweigh the risk. 

Note that CHX does not penetrate deep into the soft tissue, so it is ineffective if the infection is deep.

A typical CHX mouth rinse (0.12%) contains 11.6% alcohol and can be purchased from pharmacies, with a prescription.   The zero-alcohol CHX mouth rinse, which is relatively more expensive, may be purchased from a dental supplier, but not through a typical pharmacy.

The side effects of long-term use of CHX are teeth staining and taste alteration.

Note that patients should not use the typical Listerine which would cause sloughing off the soft tissue because it has high alcohol content. The typical Listerine contains 22.6% alcohol.  And the product generally causes soft-tissue sloughing in the mouth.

Some thought that Listerine with "free alcohol", i.e.,  LISTERINE ZERO® (the alcohol-free mouthwash), may be used instead, but the product still causes soft-tissue sloughing in the mouth.