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 a 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 a bony defect distal to the 2nd molars. A study in the literature indicates that this type of bony defect is more likely to occur in 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 as 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 pharmacists have 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 to 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 cardiovascular disease, bleeding disorders, bipolar disorder, obsessive-compulsive 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:

Acetaminophen is metabolized primarily by the liver, while ibuprofen is cleared mainly through the kidneys.

When used together at appropriate doses, acetaminophen and ibuprofen can provide effective pain relief and may reduce the need for a controlled substance such as Tylenol #3.

Some patients find that ibuprofen relieves their pain better than acetaminophen. Patients with liver disease, such as hepatitis B or C, or with elevated liver enzymes should avoid acetaminophen, while patients with bleeding disorders or stomach irritation should avoid ibuprofen.

3. Anti-inflammation (should): For certain major surgeries, significant swelling may occur in 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-inflammatory 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 Regeneration), or GBR (Guided Bone Regeneration), or extraction -- assuming an adult patient with no contraindications.

Dexamethasone reduces swelling more effectively than methylprednisolone, likely because of its longer half-life and prolonged anti-inflammatory action. Its effect is mediated by inhibition of phospholipase A2, which reduces arachidonic acid derivatives and thereby lowers prostaglandin production, including prostaglandin E2 [1].

Methylprednisolone is slightly more potent than prednisone and may provide faster symptom control in some settings, but the two are generally similarly effective when equivalent anti-inflammatory doses are used.

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)

✅ 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 due to the short duration.

Side Effects

Dexamethasone can cause short-term side effects such as insomnia, mood changes, stomach upset, hiccups, elevated blood sugar, and fluid retention. Longer or higher exposure may also increase the risk of adrenal suppression and infection.

Dexamethasone-Induced Hiccups (DIH)

Dexamethasone can definitely cause hiccups. In fact, it is one of the most well-documented medications to trigger them. Medical professionals even have a term for it: "Dexamethasone-Induced Hiccups (DIH)."

The Connection Between Dexamethasone and Hiccups

While the exact reason this happens isn't perfectly understood, scientists believe that corticosteroids like dexamethasone can lower the threshold for nerve signals in the brainstem, effectively "tripping" the reflex arc that controls your diaphragm.

Here are a few quick facts about this specific side effect:

. Who gets them: Studies show that it happens to roughly 11% of patients taking the drug. Interestingly, for reasons researchers don't quite understand yet, men are significantly more likely to experience this side effect than women.

. When they start: Hiccups usually begin anywhere from a few hours to 24 hours after taking the medication.

. How long they last: They can sometimes become persistent, lasting for several hours or even a couple of days until the medication starts clearing out of your system.

Is it a Contraindication?

It is important to distinguish between a side effect and a contraindication:

. It is not a strict contraindication: Having hiccups does not mean you are allergic to dexamethasone or that the drug is dangerously toxic to you.

. However, it can be a reason to switch: If the hiccups become severe, they can ruin your sleep, make it hard to eat, and cause abdominal pain. If they are drastically lowering your quality of life, doctors will often manage this by switching you to a different steroid (like methylprednisolone), which often stops the hiccups entirely while still doing the same medical job.

What you should do next: If you or someone you know is dealing with uncontrollable hiccups from dexamethasone, definitely call the prescribing doctor. Do not stop taking the steroid abruptly without talking to them first, but let them know so they can either prescribe a medication to stop the hiccups or swap the dexamethasone for an alternative steroid.

If preoperative dexamethasone is not feasible, take 1 tablet by mouth once daily for 3 days, with food to minimize stomach irritation.

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.

Medrol Pak (more complicated)

Active Ingredient: methylprednisolone

Brand Name: Medrol

ROA (route of administration): Oral

Inactive Ingredients: calcium stearate, cornstarch, lactose, sucrose

Medrol Pak usually means methylprednisolone dose pack, a short tapering course of a corticosteroid used to reduce inflammation and swelling. It is similar to prednisone and is often prescribed for allergic reactions, asthma flares, joint or skin inflammation, and sometimes after surgery to reduce swelling.

A typical Medrol Dosepak is a 6-day taper, with the dose decreasing each day according to the package directions.

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 a corticosteroid is harmless.

Warning: People should not take corticosteroids 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 for about 24 hr after the surgery.

Note that CHX does kill fibroblasts, but the advantage may outweigh the risk. Further, 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.

References

1. Darawade DA, Kumar S, Mehta
R, Sharma AR, Reddy GS. In search of
a better option: Dexamethasone versus
methylprednisolone in third molar impaction
surgery. J Int Oral Health.
2014 Nov-Dec;6(6):14-17. [PubMed]