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Dentistry

dentistry


We work together with dentists and their patients to solve problems using customized medications.

Medications are manufactured in a limited number of strengths and dosage forms that will satisfy the needs of most patients due to stability concerns, and the cost of stocking and distributing numerous formulations of each drug. Using pharmaceutical grade chemicals and specialized equipment not found in most pharmacies, we can compound medications in doses and dosage forms that are not commercially available. We want to optimize the care of every patient. Just let us know what you need!


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Topical Therapy for Pain and Infection

The options to help patients with oral and perioral pain problems such as neuropathies, burning mouth syndrome, neuromas and neuralgias. Vehicle-carrier agents and bases have been developed that can penetrate the mucosa and cutaneous tissues and transport the active medication to the treatment site. Dentists have been using topical agents with increasing frequency as part of the therapeutic protocol for orofacial painful neuropathy.

Several topical intraoral medications are used in the treatment of oral ulcerations and infections, including antifungals; nonsteroidal anti-inflammatory drugs (NSAIDs); and corticosteroids. Because of their rapid onset and low side-effect profile, topical medications offer a distinct advantage over systemic administration for orofacial disorders. Medicated lollipops, lozenges, and adhering powders are ideal for keeping an antibiotic or antifungal in contact with an infected area in the mouth.

Topical Anesthetics – Combinations of your Choice

Methemoglobinemia (MHb) is a potentially serious blood condition and an uncommon adverse reaction known to be associated with benzocaine. This condition reduces the ability of red blood cells to deliver oxygen throughout the body, which can lead to bluish discoloration of the skin, nausea and fatigue. It can progress to stupor, coma and death. Almost all reported cases of benzocaine-induced MHb were associated with high-concentration preparations (14 percent to 20 percent benzocaine). Compounding pharmacies can formulate low concentration or benzocaine-free topical anesthetics, including combinations of other topical anesthetics such as lidocaine and tetracaine or prilocaine.

Update on Burning Mouth Syndrome

Burning mouth syndrome (BMS), also referred to as glossopyrosis or glossodynia (when the burning occurs on the tongue only) is usually described as oral burning pain, sometimes with dysesthetic qualities similar to those present in other neuropathic pain conditions. The dorsal tongue, palate, lips and gingival tissues, individually or in combination, are the most common sites involved. Bilateral or unilateral oral burning pain has been found to be associated with jaw pain or uncontrollable tightness, taste changes, subjective dry mouth, geographic and fissured tongue, painful teeth, headache, neck and shoulder pain, difficulty speaking, nausea, gagging and swallowing difficulties. BMS has been reported to follow dental treatment, antibiotic usage and a severe upper respiratory infection. The lack of pathology to account for the pain can be frustrating. Pain is constant, progressively increases over the day, and usually decreases during eating. Patients, who are frequently distressed by their unremitting symptoms, may demonstrate psychological abnormalities including anxiety and depression.

Therapy for BMS involves the use of centrally acting medications for neuropathic pain, such as tricyclic antidepressants, benzodiazepines or gabapentin. Clonazepam is a benzodiazepine used either topically or in low doses orally, which appears to have excellent efficacy in the relief of the symptoms related to BMS. Topical medications, including clonidine, may be considered for application to local sites.

A combination of oral medications for the management of BMS (clonazepam, gabapentin, baclofen, and lamotrigine) significantly decreased pain in 38 or 45 patients. The most common adverse effect reported with the medication protocol was drowsiness followed by dizziness and perceived changes in mood. These results suggest that BMS may be treated with lower doses of a combination of medications rather than higher doses of a single medication, which may help to limit adverse effects such as drowsiness or dizziness.

Adv Otorhinolaryngol. 2006, 63:278-287

The formulation for a mouthrinse containing clonazepam 1 mg per 5 ml has been reported. It is hypothesised that clonazepam acts locally to disrupt the mechanism(s) underlying stomatodynia. Topical formulations of gabapentin, ketamine, clonidine, and baclofen have been used to treat chronic neuropathic pain at various bodily sites.

Int J of Pharmaceutical Compounding July/Aug 2005, 9(4):310
Pain 2004 Mar;108(1-2):51-7 (click for abstract)
Pain Med. 2000 Mar;1(1):97-100

Triamcinolone Acetonide Oral Rinse for Treating Oral Lichen Planus

Corticosteroids are the class of drug most commonly used for the treatment of oral lichen planus. Triamcinolone acetonide paste is the most widely available commercial preparation for the treatment of oral lichen planus, but is difficult to apply to mucosa and patients have reported an unpleasant sticky sensation. Delivery of corticosteroids via an oral rinse has the advantage of providing drug contact with the distal, hard-to-reach crevices and surfaces of the oral cavity, which can prevent new eruptions.

The use of a 0.1% triamcinolone acetonide aqueous suspension as an oral rinse in the treatment of symptomatic oral lichen planus has proven to be more effective than the 0.1% dental paste. This preparation must be compounded extemporaneously and should not contain flavorings (which stimulate salivation and therefore dilute the preparation in the mouth, decreasing its effectiveness) or preservatives (which may sting or burn the mucosa). Also, researchers have formulated a triamcinolone acetonide solution for use as an oral rinse, which is more convenient to use and more palatable than the commercially available triamcinolone acetonide paste, with similar therapeutic efficacy.

Am J Health-Syst Pharm. 2005;62(5):485-491


Formulation and efficacy of triamcinolone acetonide mouthwash for treating oral lichen planus.


Click here
to access the PubMed abstract of this article.


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Dry Mouth, Stomatitis, and Mucositis

Misoprostol: Mucosal Protectant and Anti-Secretory

Misoprostol is a synthetic prostaglandin E1 analogue, with mucosal cytoprotectant and antisecretory properties. A mouthrinse containing misoprostol and lidocaine in a non-irritating neutral vehicle can be used to provide immediate pain relief and aid in the healing of the oral cavity.

A mucoadhesive powder containing misoprostol can be used to aid in the healing of mucosal ulcers and irritations. It is applied by using a powder “puffer” or by direct application of the powder to the affected area. The carriers will hydrate and adhere to the mucosal surface, keeping the misoprostol in prolonged contact with the area.

Int’l J Pharm Compounding. May/June 2000; 4(3):211-212 Click here to access the abstract of this article.
Int’l J Pharm Compounding. Jan/Feb 1999; 3(1):48 Click here to access the abstract of this article

Burning Mouth Syndrome (BMS) Relieved with Alpha Lipoic Acid (ALA)

A double blind, controlled study compared alpha lipoic acid with placebo for two months on 60 patients with constant BMS, in whom there was no laboratory evidence of deficiencies in iron, vitamins or thyroid function and no hyperglycemia. Following treatment with alpha lipoic acid 600 mg orally daily, there was a significant symptomatic improvement compared with placebo. This improvement was maintained in over 70% of patients at the 1 year follow-up.

J Oral Pathol Med. 2002 May;31(5):267-9.
Burning mouth syndrome (BMS): double blind controlled study of alpha-lipoic acid (thioctic acid) therapy.

Femiano F, Scully C
Stomatology Clinic II, University of Medicine and Surgery, Napoli, Italy.

Click here to access the PubMed abstract of this article.

Saliva Substitute for Dry Mouth/Throat

Saliva replacement is an important adjunct to relieving the symptoms of xerostomia in patients with Sjogren’s Syndrome. Saliva substitutes which contain thickening agents like carboxymethylcellulose are used because water alone can not adequately moisten and lubricate the oral mucosa and teeth. Dry mouth or throat secondary to a number of conditions can be relieved with a customized saliva substitute that can be administered throughout the day and night and can be flavored to please each patient. Keeping the mucosal membranes moist can improve comfort for the patient and minimize irritation and the risk of infection.

Int’l J Pharm Compounding. May/June 2000; 4(3):215 Click here to access the abstract of this article.
Int’l J Pharm Compounding. Sep/Oct 2000; 4(5):340 Click here to access the abstract of this article.

Pilocarpine Troches for Xerostomia

Pilocarpine is indicated for the treatment of xerostomia secondary to radiation therapy of the head and neck. Pilocarpine is a cholinergic agent that stimulates residual-functioning exocrine glands. In a study by Vivino et al., pilocarpine at oral doses of 2.5mg and 5mg four times daily significantly increased saliva production and alleviated symptoms of dry mouth when compared to placebo. The higher dose produced the most improvement but also the highest incidence of adverse effects, such as sweating, diarrhea, and urinary frequency.

Arch Intern Med. 1999; 159:174-181
Pilocarpine tablets for the treatment of dry mouth and dry eye symptoms in patients with Sjogren’s Syndrome: a randomized, placebo-controlled, fixed-dose, multicenter trial. P92-01 Study Group.

Vivino FB, Al-Hashimi I, Khan Z, LeVeque FG, Salisbury PL 3rd, Tran-Johnson TK, Muscoplat CC, Trivedi M, Goldlust B, Gallagher SC.
Division of Rheumatology, University of Pennsylvania Health System, Philadelphia, USA.

Click here to access the PubMed abstract of this article.

Int’l J Pharm Compounding. Sep/Oct 2000; 4(5):381 Click here to access the abstract of this article.

Treatment for Dry Mouth, Stomatitis, and Mucositis

Loss of saliva (xerostomia) is one of the most common complaints among patients who have received radiation therapy of the head and neck. Xerostomia contributes to radiation-induced periodontal infection, dental caries, osteoradionecrosis, and poor digestion of carbohydrates. Ask us about sialogogues (saliva stimulants) in customized dosage forms.

Aust Dent J 2002 Sep;47(3):249-53
An investigation into the use of pilocarpine as a sialagogue in patients with radiation induced xerostomia.

Frydrych AM, Davies GR, Slack-Smith LM, Heywood J.
School of Dentistry, The University of Western Australia, Crawley.

Click here to access the PubMed abstract of this article.

When a person is receiving chemotherapy or radiation, mouth tenderness and infections can interfere with the ability to eat. Malnutrition may result, yet it is often preventable. Our pharmacy can compound medications which may enable patients to enjoy eating again. We can compound numerous medications into a preparation such as an oral rinse that contains the needed concentrations of each drug.

A three-drug mouthwash (lidocaine, diphenhydramine and sodium bicarbonate in normal saline) can provide effective symptomatic relief in patients with chemotherapy-induced mucositis.

Support Care Cancer. 2000 Jan;8(1):55-8
Efficacy of treatment to relieve mucositis-induced discomfort.

Turhal NS, Erdal S, Karacay S.
Department of Medicine, Marmara University Hospital, Istanbul, Turkey.

Click here to access the PubMed abstract of this article.


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Therapy for Temporo-Mandibular Joint Disorder (TMJ)

Transdermal application of NSAIDs such as ketoprofen results in significantly higher tissue levels beneath the site of application than are achieved with oral administration. Additionally, side effects such as gastrointestinal irritation are avoided.

The following article concludes: “Topical non-steroidal anti-inflammatory drugs are effective in relieving pain in acute and chronic conditions.”

BMJ. 1998 Jan 31;316(7128):333-8
Quantitative systematic review of topically applied non-steroidal anti-inflammatory drugs.

Moore RA, Tramer MR, Carroll D, Wiffen PJ, McQuay HJ.
University of Oxford, Oxford Radcliffe Hospital, Headington.
Click here to access the PubMed abstract of this article.

Free full text article available at bmj.com: http://bmj.bmjjournals.com/cgi/content/full/316/7128/333

The following article reports “The systemic concentrations of ketoprofen have also been found to be 100 fold lower compared to tissue concentrations below the application… Topically applied ketoprofen thus provides high local concentration below the site of application but lower systemic exposure.”

Pharm Res. 1996 Jan;13(1):168-72
Percutaneous absorption of ketoprofen from different anatomical sites in man.

Shah AK, Wei G, Lanman RC, Bhargava VO, Weir SJ.
Pfizer Inc., Central Research Division, Groton, Connecticut 06340, USA.
Click here to access the PubMed abstract of this article.

Iontophoretic delivery of dexamethasone and lidocaine may be effective in improving mandibular function in patients with temporo-mandibular disorders who have concurrent temporo-mandibular joint capsulitis and disc displacement without reduction.

J Orofac Pain 1996 Spring;10(2):157-65
Temporomandibular joint iontophoresis: a double-blind randomized clinical trial.

Schiffman EL, Braun BL, Lindgren BR.
TMJ and Craniofacial Pain Clinic, School of Dentistry University of Minnesota, Minneapolis 55455
Click here to access the PubMed abstract of this article.


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Suppressing the Gag Reflex

The gag reflex can cause a patient considerable discomfort as well as interfere with dental procedures. An electrolyte tablet administered and retained intraorally a few minutes before the start of a procedure can suppress the gag reflex, allowing a mandibular block to be given with much greater ease, which further reduces the gagging reflex.

Tablets can be prescribed for home use for patients who can not properly perform oral hygiene procedures due to the gagging problem. Severe gaggers may need to repeat a dose in 15 to 20 minutes. (Dent Today. 1991 Dec;10(9):68-71)

Some patients and dentists prefer to use electrolyte lollipops.


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Transdermal Anti-Emetics

Topical application of anti-emetics in a gel formulation provides a rapid onset and offers an effective alternative to oral administration. Oral surgeons have found this formulation to be particularly useful.

Promethazine is commonly compounded for topical or transdermal application to treat nausea, vomiting, and vertigo, but this preparation may be used as an antiemetic for cases ranging from chemotherapy to motion sickness. The dose is typically 25mg for adults, and the dose is decreased for children. The gel is applied to an area of soft skin, such as the inside of the wrist or arm, the side of the torso, or the inside of the thigh. For children, the gel is often applied to the inside of one wrist, and then the wrists are rubbed together.
US Pharmacist, August 1999; 74-5

Other dosage forms include suppositories and lollipops.


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Periodontal Therapy

Compounding allows countless active ingredients to be incorporated into customized mouthwashes, gels, troches, etc. For example, to treat periodontal disease, antibiotics can be formulated as a mouthwash, or added to an oral adhesive paste or a plasticized gel that will maintain the contact between the tissue and medication for a prolonged period of time.

Metronidazole 25% in a lipogel-type base provides an efficient treatment of anaerobic infection when applied topically in the periodontal pockets.

Click on the following citations for abstracts/more information:
J Int Acad Periodontol. 2000 Jul;2(3):64-70
Vojnosanit Pregl. 2005 Jul-Aug;62(7-8):565-8
Minerva Stomatol. 2000 Jan-Feb;49(1-2):59-67
J Clin Periodontol. 1992 Oct;19(9 Pt 2):693-7


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“Miracle Mouthwashes”

Compounding dental mouthwashes or rinses may offer numerous advantages over commercially available dosage forms. Elixirs, syrups, and suspensions often contain preservatives such as alcohol which can cause reactions or gastrointestinal irritation, or sugar which makes the preparation undesirable for prolonged use in the mouth or for diabetic patients. A customized preparation without unnecessary excipients – i.e., a sugar-free, dye-free, lactose-free, and preservative-free dosage form – can eliminate concerns of palatability, alcohol content, and dyes which may stain exposed mucosa.

Various preparations are also available to treat burning mouth syndrome and anesthetic/analgesic and antibiotic/anti-infective mouthwashes are commonly requested.

Tranexamic acid solution (4.8%) used as a mouthwash has been used successfully to prevent postsurgical bleeding after oral surgery without dose modification of oral anticoagulants.

J Oral Maxillofac Surg 1993 Nov;51(11):1211-6
Prevention of postsurgical bleeding in oral surgery using tranexamic acid without dose modification of oral anticoagulants.

Ramstrom G, Sindet-Pedersen S, Hall G, Blomback M, Alander U
Department of Oral and Jaw Diseases, Karolinska Hospital, Stockholm, Sweden.

Click here to access the PubMed abstract of this article.


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Examples of compounded medications

All formulations are customized per prescription to meet the unique needs of each patient. Please contact our compounding pharmacist to discuss the dosage form, strength, and medication or combination that is most appropriate for your patient.

Upon a prescription order, we can compound:

  • lip balms for viral lesions
  • topical muscle relaxants/analgesics
  • topical anesthetics
  • non-staining antibacterial rinses
  • oral sedation in lollipops and freezer pops
  • lollipops for oral thrush
  • mouth rinses for aphthous ulcers or chemotherapy-induced stomatitis
  • mouth rinse to stop oral bleeding during dental procedures for patients who take anticoagulants
  • dry socket preparations
  • “mucosal bandages” to cover ulcerated, infected, or tender mucosa
  • lozenges that help to prevent gagging
  • and many more unique preparations and novel delivery systems

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