Dentistry

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

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

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!

Fluconazole Mouthrinse for Candidiasis

Candidiasis is one of the most common oral fungal infections in humans. Localized oral candidiasis should be managed initially with local treatment confined to the site of involvement before systemic antifungal drugs are used. Recognition of the potential risk and early treatment of oral candidiasis may prevent serious morbidity in high-risk patients.

A study evaluated the efficacy of fluconazole mouthrinse compared to clotrimazole mouthpaint in the treatment of oral candidiasis. 43 patients were treated with fluconazole mouthrinse (Group A) and 46 patients were treated with clotrimazole mouthpaint (Group B). The clinical resolution rates in Group A and Group B were 96% and 78%, respectively. More fluconazole-treated patients remained disease-free during the 15 day follow-up than those treated with clotrimazole. Both treatment regimens were well tolerated. Although the number of patients in the present study was small, the outcome was promising. Additionally, the dose of fluconazole used per day was only 30 mg, which is less than one-third of the standard oral dose of fluconazole (100 mg). 

Note: These preparations may not be effective in the treatment of widespread severe oral candidiasis in immuno-compromised patients. 

Australian Dental Journal 2009: 54: 341-6.
Comparison of efficacy of fluconazole mouthrinse and clotrimazole mouthpaint in the treatment of oral candidiasis
Click here to read the abstract of this article.

Cold sores? Looking for a Natural Remedy? 

2-Deoxy D-Glucose is a sugar derivative sometimes referred to as Nature’s Antiviral. 2-DDG can inhibit the replication of herpes simplex virus (HSV) which causes cold sores. Ask us about compounded lip balms.

Ketoconazole Lollipops or Lozenges Can Improve Compliance with Therapy for Oral Thrush 

The following study examined the use of medicated flavored lollipops that each contained 15 mg of ketoconazole. A hydrophilic polymer was added to increase the retention time of the drug in the mouth. The study concluded that medicated lollipops or lozenges are ideal dosage forms for treatment of pediatric patients with oral thrush. Stability studies at room temperatures showed that the formulations were stable for 3 months. 

Int. J. LifeSc. Bt & Pharm. Res. 2012; 1(1): 95 – 102.
Medicated Lollipops for the Treatment of Oral Thrush in Children
Click here to read the PubMed abstract of this article.

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.

Treatment for Recurrent Aphthous Stomatitis

In a clinical randomized crossover trial, minocycline 0.2% and tetracycline 0.25% aqueous oral rinses were assessed in patients with frequent episodes of RAS. Minocycline mouthwashes as compared to topical tetracycline rinses resulted in significantly improved pain control, by reducing the severity and duration of pain. Topical minocycline rinse may be a potential treatment for other non-infectious inflammatory ulcerative oral mucosal diseases.

Dermatol Online J. 2007 May 1;13(2):1.
Topical minocycline and tetracycline rinses in treatment of recurrent aphthous stomatitis: a randomized cross-over study.
Click here to read the PubMed abstract of this article.

Spec Care Dentist. 2008 Jan-Feb;28(1):27-31.
Topical minocycline for managing symptoms of recurrent aphthous stomatitis.
Click here to read the PubMed abstract of this article.

A single-blind controlled study evaluated the therapeutic efficacy and safety of lactic acid 5% mouthwash, one teaspoonful three times daily before meals, and concluded that this is an effective therapy for patients with RAS and significantly reduced the signs and symptoms of the disease.

Dermatol Online J. 2006 Dec 10;12(7):2.
Lactic acid 5 percent mouthwash is an effective mode of therapy in treatment of recurrent aphthous ulcerations.
Click here to read the PubMed abstract of this article.

Dyclonine Topical Anesthetic Solution

Dyclonine HCl 0.5% and 1.0% Topical Solutions are listed in the “Discontinued Drug Product List” section of the Orange Book as Dyclone™ products were NOT withdrawn from commercial manufacture for reasons of safety or effectiveness. Unlike the original product which had an unpleasant taste, compounded dyclonine topical anesthetic solution can be formulated in mint and several other pleasing flavors.

Topical Medication to Treat Orofacial Neuropathic Pain

The Department of Diagnostic Sciences, Division of Orofacial Pain, University of Medicine and Dentistry of New Jersey, Newark, conducted a study to evaluate the effect of topical medications alone or in combination with systemic medications in the treatment of orofacial neuropathic pain conditions. A retrospective chart review was performed for 39 patients who were diagnosed with a neuropathic pain condition such as deafferentation pain, traumatic neuroma, or trigeminal or glossopharyngeal neuralgia, and were treated for orofacial neuropathic pain at the Orofacial Pain Clinic.

The review concluded that topical medication as single treatment or in combination with systemic medications can reduce orofacial neuropathic pain severity.

“The topical medication can be ordered from a compounding pharmacy where it can be formulated to contain carbamazepine 4%, lidocaine 1%, ketoprofen 4%, ketamine 4%, and gabapentin 4%. Carbamazepine and gabapentin ... act by suppressing paroxysmal discharges and reducing neuronal hyperexcitability. Lidocaine, which is a local anesthetic, acts by blocking sodium channels, preventing nerve depolarization. Ketoprofen has anti-inflammatory activity. Last, ketamine blocks N-methyl-D-aspartate (NMDA) receptors, whose hyperactivity contributes to maintenance of neuropathic pain.” The topical preparation should utilize penetration enhancers such as anhydrous gel base and bio-adhesive copolymers. These are used to carry the medication transdermally and transmucosally. “

Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008 Apr;105(4):466-9.
Use of topical medication in orofacial neuropathic pain: a retrospective study.
Click here to read the PubMed abstract of this article.

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;63:278-87.
Burning mouth syndrome.
Click here to view the abstract of this article.

The formulation for a mouthrinse containing clonazepam 1 mg per 5 ml has been reported. It is hypothesized 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 Pharm Compd. July/Aug 2005, 9(4):310
BMS Mouthwash
Click here to view the abstract of this article.

Pain. 2004 Mar;108(1-2):51-7.
Topical clonazepam in stomatodynia: a randomised placebo-controlled study.
Click here to read the PubMed abstract of this article.

Pain Med. 2000 Mar;1(1):97-100.
Topical ketamine gel: possible role in treating neuropathic pain.
Click here to read the PubMed abstract of this article.

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 flavoring (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 Mar 1;62(5):485-91.
Formulation and efficacy of triamcinolone acetonide mouthwash for treating oral lichen planus
Click here to view the abstract of this article.

Topical Melatonin: Radiation-Induced Oral Mucositis

For 21 days post-radiation to the tongue, male Wistar rats were treated with 45 mg/day melatonin gel or vehicle, locally applied into their mouths. The application of melatonin gel restored physiological melatonin levels in the tongue and prevented mucosal disruption and ulcer formation. Melatonin gel protected the mitochondria from radiation damage and blunted the inflammasome signaling activation in the tongue, suggesting a potential preventive therapy for mucositis in patients with cancer.

J Pineal Res. 2015 Jan;58(1):34-49.
Melatonin blunts the mitochondrial/NLRP3 connection and protects against radiation-induced oral mucositis. 
Click here to access the PubMed abstract of this article.

L-Glutamine Decreases the Severity of Chemotherapy-Induced Mucositis and Oral Pain 

Glutamine is a nutrient for rapidly dividing cells and the major energy source for intestinal epithelium. The incidence of severe mucositis in the oral cavity, pharynx and larynx is high among patients with head and neck cancer (HNC) receiving chemoradiotherapy (CRT), resulting in significant pain and impairment of quality of life. A double-blind, randomized, placebo-controlled showed that glutamine significantly decreased the maximal mucositis grade and pain score at weeks 4, 5 and 6.

Nutrition. 2015 Jan;31(1):200-4. 
Effects of oral glutamine during abdominal radiotherapy on chronic radiation enteritis: a randomized controlled trial.
Click here to access the PubMed abstract of this article.

Anderson et al. of the Mayo Clinic reported that administration of glutamine suspension after chemotherapy (2 g/m2/dose for adults, swish and swallow twice daily on days of chemotherapy and for at least 14 additional days) has resulted in significant amelioration of stomatitis (duration of mouth pain was 4.5 days less when compared to placebo). The severity of oral pain was also reduced significantly when glutamine was provided with chemotherapy - the amount of days mucositis restricted oral intake to soft foods was 4 days less with glutamine. No toxicity of glutamine was observed. Oral glutamine appears to be a simple and useful measure to increase the comfort of many patients at high risk of developing mouth sores as a consequence of chemotherapy. 

Cancer 1998 Oct 1;83(7):1433-9 
Oral glutamine reduces the duration and severity of stomatitis after cytotoxic cancer chemotherapy.
Click here to access the PubMed abstract of this article.

Oral mucositis (mouth sores and/or difficulty swallowing) continues to be a common and debilitating side effect of the conditioning regimens that use high-dose chemotherapy with or without radiation for pediatric bone marrow transplantation. Severe mucositis is a common cause of morbidity in hematopoietic stem cell transplant (HSCT) recipients. Physicians may want to consider oral glutamine supplementation as a routine part of supportive care of Stem Cell Transplantation (SCT) patients.

Oncol Rep. 2015 Jan;33(1):33-9. 
L-glutamine decreases the severity of mucositis induced by chemoradiotherapy in patients with locally advanced head and neck cancer: a double-blind, randomized, placebo-controlled trial.
Click here to access the PubMed abstract of this article.

Topical Oral Solutions for the Treatment of Chemo-Induced Oral Mucositis

“Magic mouthwashes” are topical solutions or suspensions prepared to relieve symptoms of various oral pathologies. As compounding pharmacists, we recognize the need for practitioners to have the ability to prescribe customized preparations to meet specific patient needs. We can compound various medications into a stable, pleasantly-flavored, alcohol-free suspension.
 
J Oncol Pharm Pract. 2005 Dec;11(4):139-43.
Survey of topical oral solutions for the treatment of chemo-induced oral mucositis.
Click here to access the PubMed abstract of this article.

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
Misoprostol 0.001% and Lidocaine 0.5% Oral Rinse
Click here to access the abstract of this article.

Int'l J Pharm Compounding. May/June 2000; 4(3):212
Misoprostol 0.0027% Mucoadhesive Powder
Click here to access the abstract of this article.

Int'l J Pharm Compounding. Jan/Feb 1999; 3(1):48
Misoprostol 0.0024% and Lidocaine 1% in Glycerin Mouth Paint 
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.
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 flavoured to please each patient. Keeping the mucosal membranes moist can improve comfort for the patient and minimise irritation and the risk of infection.

Int'l J Pharm Compounding. May/June 2000; 4(3):215
Saliva Substitute for Dry Mouth/Throat 
Click here to access the abstract of this article.

Int'l J Pharm Compounding. Sep/Oct 2000; 4(5):340
Saliva Substitute
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, diarrhoea, 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 syndrome: a randomised, placebo-controlled, fixed-dose, multicenter trial. P92-01 Study Group.
Click here to access the PubMed abstract of this article.

Int'l J Pharm Compounding. Sep/Oct 2000; 4(5):381
Pilocarpine HCl 2-mg Troches 
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.
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.
Click here to access the PubMed abstract of this article.

New, Noninvasive Approach for Successfully Treating Pain and Inflammation of TMJ Disorders

A topical gel containing 18% potassium complex, 10% dimethylisosorbide, and 72% aqueous hydroxyethyl cellulose gel was applied and gently rubbed onto the facial skin over the painful TMJ, muscles of mastication, and myofacial area. Complete pain relief occurred in 45 of 54 patients in this study within 5 minutes of the first application of the gel, and in all 54 patients after the third day of twice daily application of the treatment gel.

J Oral Implantol. 2007;33(6):365-70. 
A new, noninvasive approach for successfully treating the pain and inflammation of TMJ disorders.
Click here to read the PubMed abstract of this article.

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.
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.
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.
Click here to access the PubMed abstract of this article.

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.

Some patients and dentists prefer to use electrolyte lollipops.

Dent Today. 1991 Dec;10(9):68-71
The gagging patient: a method for success.
Click here to access the PubMed abstract of this article.

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.

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.

J Int Acad Periodontol. 2000 Jul;2(3):64-70 
Clinical evaluation of subgingival application of metronidazole 25%, and adjunctive therapy.
Click here to access the PubMed abstract of this article.

Vojnosanit Pregl. 2005 Jul-Aug;62(7-8):565-8 
Effects of topical application of metronidazole-containing mucoadhesive lipogel in periodontal pockets.
Click here to access the PubMed abstract of this article.

Minerva Stomatol. 2000 Jan-Feb;49(1-2):59-67 
[Topical treatment of peri-implantitis with metronidazole dental gel 25%. Clinical analysis and microbiological control]
Click here to access the PubMed abstract of this article.

J Clin Periodontol. 1992 Oct;19(9 Pt 2):693-7
Systemic absorption of metronidazole after application of a metronidazole 25% dental gel.
Click here to access the PubMed abstract of this article.

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.

Ryan et al. of the Department of Pharmacy, University of California San Diego, La Jolla, CA, sought to determine if an oral ketamine “swish and expectorate” mouthwash was a safe and effective method to alleviate mucositis pain. They concluded that a ketamine mouthwash administered using the “swish and spit” technique may be a viable treatment option in refractory mucositis pain.

J Palliat Med. 2009 Nov;12(11):989-91.
Ketamine mouthwash for mucositis pain. Ryan AJ, Lin F, Atayee RS.
Click here to access the PubMed abstract of this article.  

“Magic mouthwashes” are topical solutions or suspensions prepared to relieve symptoms of various oral pathologies. A study conducted at the Department of Clinical Pharmacy, University of California, San Francisco, described the usage of topical oral solutions in patients experiencing chemotherapy-induced oral mucositis (CIOM), and surveyed the care of oral mucositis provided to patients by clinical oncology pharmacists in institutional settings. The top five ingredients used to compound “magic mouthwash” were reported to be diphenhydramine, viscous lidocaine, magnesium hydroxide/aluminum hydroxide, nystatin and corticosteroids. Most institutions administer the mouthwash every 4 hours or every 6 hours.

J Oncol Pharm Pract. 2005 Dec;11(4):139-43.
Survey of topical oral solutions for the treatment of chemo-induced oral mucositis. Chan A, Ignoffo RJ.
Click here to access the PubMed abstract of this article.  

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.
Click here to access the PubMed abstract of this article.

We are dedicated to meeting the unique needs of dental patients, and we welcome your questions and medication problems. Our compounding professionals are problem-solving specialists! Examples of Customized Medications for Dental Care

• Anti-Viral Lip Balms
• Ketamine/Ketoprofen/Gabapentin gel
• Ketoprofen/Cyclobenzaprine topical gel
• Lidocaine/Prilocaine gel in plasticized base
• Mucosal Bandages Oxytetracycline/Hydrocortisone Suspension
• Peruvian Balsam/Eugenol
• Sucralfate Oral Adhesive Paste
• Tranexamic Acid Mouthwash
• Triple-Anesthetic gel - benzocaine/lidocaine/tetracaine ("BLT")
• Pressure Indicating Paste (PIP)

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.

Dentistry

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

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

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!

©Storey Marketing. Used with permission. All rights reserved.

Fluconazole Mouthrinse for Candidiasis

Candidiasis is one of the most common oral fungal infections in humans. Localized oral candidiasis should be managed initially with local treatment confined to the site of involvement before systemic antifungal drugs are used. Recognition of the potential risk and early treatment of oral candidiasis may prevent serious morbidity in high-risk patients.

A study evaluated the efficacy of fluconazole mouthrinse compared to clotrimazole mouthpaint in the treatment of oral candidiasis. 43 patients were treated with fluconazole mouthrinse (Group A) and 46 patients were treated with clotrimazole mouthpaint (Group B). The clinical resolution rates in Group A and Group B were 96% and 78%, respectively. More fluconazole-treated patients remained disease-free during the 15 day follow-up than those treated with clotrimazole. Both treatment regimens were well tolerated. Although the number of patients in the present study was small, the outcome was promising. Additionally, the dose of fluconazole used per day was only 30 mg, which is less than one-third of the standard oral dose of fluconazole (100 mg). 

Note: These preparations may not be effective in the treatment of widespread severe oral candidiasis in immuno-compromised patients. 

Australian Dental Journal 2009: 54: 341-6.
Comparison of efficacy of fluconazole mouthrinse and clotrimazole mouthpaint in the treatment of oral candidiasis
Click here to read the abstract of this article.

Cold sores? Looking for a Natural Remedy? 

2-Deoxy D-Glucose is a sugar derivative sometimes referred to as Nature’s Antiviral. 2-DDG can inhibit the replication of herpes simplex virus (HSV) which causes cold sores. Ask us about compounded lip balms.

Ketoconazole Lollipops or Lozenges Can Improve Compliance with Therapy for Oral Thrush 

The following study examined the use of medicated flavored lollipops that each contained 15 mg of ketoconazole. A hydrophilic polymer was added to increase the retention time of the drug in the mouth. The study concluded that medicated lollipops or lozenges are ideal dosage forms for treatment of pediatric patients with oral thrush. Stability studies at room temperatures showed that the formulations were stable for 3 months. 

Int. J. LifeSc. Bt & Pharm. Res. 2012; 1(1): 95 – 102.
Medicated Lollipops for the Treatment of Oral Thrush in Children
Click here to read the PubMed abstract of this article.

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.

Treatment for Recurrent Aphthous Stomatitis

In a clinical randomized crossover trial, minocycline 0.2% and tetracycline 0.25% aqueous oral rinses were assessed in patients with frequent episodes of RAS. Minocycline mouthwashes as compared to topical tetracycline rinses resulted in significantly improved pain control, by reducing the severity and duration of pain. Topical minocycline rinse may be a potential treatment for other non-infectious inflammatory ulcerative oral mucosal diseases.

Dermatol Online J. 2007 May 1;13(2):1.
Topical minocycline and tetracycline rinses in treatment of recurrent aphthous stomatitis: a randomized cross-over study.
Click here to read the PubMed abstract of this article.

Spec Care Dentist. 2008 Jan-Feb;28(1):27-31.
Topical minocycline for managing symptoms of recurrent aphthous stomatitis.
Click here to read the PubMed abstract of this article.

A single-blind controlled study evaluated the therapeutic efficacy and safety of lactic acid 5% mouthwash, one teaspoonful three times daily before meals, and concluded that this is an effective therapy for patients with RAS and significantly reduced the signs and symptoms of the disease.

Dermatol Online J. 2006 Dec 10;12(7):2.
Lactic acid 5 percent mouthwash is an effective mode of therapy in treatment of recurrent aphthous ulcerations.
Click here to read the PubMed abstract of this article.

Dyclonine Topical Anesthetic Solution

Dyclonine HCl 0.5% and 1.0% Topical Solutions are listed in the “Discontinued Drug Product List” section of the Orange Book as Dyclone™ products were NOT withdrawn from commercial manufacture for reasons of safety or effectiveness. Unlike the original product which had an unpleasant taste, compounded dyclonine topical anesthetic solution can be formulated in mint and several other pleasing flavors.

Topical Medication to Treat Orofacial Neuropathic Pain

The Department of Diagnostic Sciences, Division of Orofacial Pain, University of Medicine and Dentistry of New Jersey, Newark, conducted a study to evaluate the effect of topical medications alone or in combination with systemic medications in the treatment of orofacial neuropathic pain conditions. A retrospective chart review was performed for 39 patients who were diagnosed with a neuropathic pain condition such as deafferentation pain, traumatic neuroma, or trigeminal or glossopharyngeal neuralgia, and were treated for orofacial neuropathic pain at the Orofacial Pain Clinic.

The review concluded that topical medication as single treatment or in combination with systemic medications can reduce orofacial neuropathic pain severity.

“The topical medication can be ordered from a compounding pharmacy where it can be formulated to contain carbamazepine 4%, lidocaine 1%, ketoprofen 4%, ketamine 4%, and gabapentin 4%. Carbamazepine and gabapentin ... act by suppressing paroxysmal discharges and reducing neuronal hyperexcitability. Lidocaine, which is a local anesthetic, acts by blocking sodium channels, preventing nerve depolarization. Ketoprofen has anti-inflammatory activity. Last, ketamine blocks N-methyl-D-aspartate (NMDA) receptors, whose hyperactivity contributes to maintenance of neuropathic pain.” The topical preparation should utilize penetration enhancers such as anhydrous gel base and bio-adhesive copolymers. These are used to carry the medication transdermally and transmucosally. “

Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008 Apr;105(4):466-9.
Use of topical medication in orofacial neuropathic pain: a retrospective study.
Click here to read the PubMed abstract of this article.

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;63:278-87.
Burning mouth syndrome.
Click here to view the abstract of this article.

The formulation for a mouthrinse containing clonazepam 1 mg per 5 ml has been reported. It is hypothesized 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 Pharm Compd. July/Aug 2005, 9(4):310
BMS Mouthwash
Click here to view the abstract of this article.

Pain. 2004 Mar;108(1-2):51-7.
Topical clonazepam in stomatodynia: a randomised placebo-controlled study.
Click here to read the PubMed abstract of this article.

Pain Med. 2000 Mar;1(1):97-100.
Topical ketamine gel: possible role in treating neuropathic pain.
Click here to read the PubMed abstract of this article.

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 flavoring (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 Mar 1;62(5):485-91.
Formulation and efficacy of triamcinolone acetonide mouthwash for treating oral lichen planus
Click here to view the abstract of this article.

©Storey Marketing. Used with permission. All rights reserved.






Topical Melatonin: Radiation-Induced Oral Mucositis

For 21 days post-radiation to the tongue, male Wistar rats were treated with 45 mg/day melatonin gel or vehicle, locally applied into their mouths. The application of melatonin gel restored physiological melatonin levels in the tongue and prevented mucosal disruption and ulcer formation. Melatonin gel protected the mitochondria from radiation damage and blunted the inflammasome signaling activation in the tongue, suggesting a potential preventive therapy for mucositis in patients with cancer.

J Pineal Res. 2015 Jan;58(1):34-49.
Melatonin blunts the mitochondrial/NLRP3 connection and protects against radiation-induced oral mucositis. 
Click here to access the PubMed abstract of this article.

L-Glutamine Decreases the Severity of Chemotherapy-Induced Mucositis and Oral Pain 

Glutamine is a nutrient for rapidly dividing cells and the major energy source for intestinal epithelium. The incidence of severe mucositis in the oral cavity, pharynx and larynx is high among patients with head and neck cancer (HNC) receiving chemoradiotherapy (CRT), resulting in significant pain and impairment of quality of life. A double-blind, randomized, placebo-controlled showed that glutamine significantly decreased the maximal mucositis grade and pain score at weeks 4, 5 and 6.

Nutrition. 2015 Jan;31(1):200-4. 
Effects of oral glutamine during abdominal radiotherapy on chronic radiation enteritis: a randomized controlled trial.
Click here to access the PubMed abstract of this article.

Anderson et al. of the Mayo Clinic reported that administration of glutamine suspension after chemotherapy (2 g/m2/dose for adults, swish and swallow twice daily on days of chemotherapy and for at least 14 additional days) has resulted in significant amelioration of stomatitis (duration of mouth pain was 4.5 days less when compared to placebo). The severity of oral pain was also reduced significantly when glutamine was provided with chemotherapy - the amount of days mucositis restricted oral intake to soft foods was 4 days less with glutamine. No toxicity of glutamine was observed. Oral glutamine appears to be a simple and useful measure to increase the comfort of many patients at high risk of developing mouth sores as a consequence of chemotherapy. 

Cancer 1998 Oct 1;83(7):1433-9 
Oral glutamine reduces the duration and severity of stomatitis after cytotoxic cancer chemotherapy.
Click here to access the PubMed abstract of this article.

Oral mucositis (mouth sores and/or difficulty swallowing) continues to be a common and debilitating side effect of the conditioning regimens that use high-dose chemotherapy with or without radiation for pediatric bone marrow transplantation. Severe mucositis is a common cause of morbidity in hematopoietic stem cell transplant (HSCT) recipients. Physicians may want to consider oral glutamine supplementation as a routine part of supportive care of Stem Cell Transplantation (SCT) patients.

Oncol Rep. 2015 Jan;33(1):33-9. 
L-glutamine decreases the severity of mucositis induced by chemoradiotherapy in patients with locally advanced head and neck cancer: a double-blind, randomized, placebo-controlled trial.
Click here to access the PubMed abstract of this article.

Topical Oral Solutions for the Treatment of Chemo-Induced Oral Mucositis

“Magic mouthwashes” are topical solutions or suspensions prepared to relieve symptoms of various oral pathologies. As compounding pharmacists, we recognize the need for practitioners to have the ability to prescribe customized preparations to meet specific patient needs. We can compound various medications into a stable, pleasantly-flavored, alcohol-free suspension.
 
J Oncol Pharm Pract. 2005 Dec;11(4):139-43.
Survey of topical oral solutions for the treatment of chemo-induced oral mucositis.
Click here to access the PubMed abstract of this article.

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
Misoprostol 0.001% and Lidocaine 0.5% Oral Rinse
Click here to access the abstract of this article.

Int'l J Pharm Compounding. May/June 2000; 4(3):212
Misoprostol 0.0027% Mucoadhesive Powder
Click here to access the abstract of this article.

Int'l J Pharm Compounding. Jan/Feb 1999; 3(1):48
Misoprostol 0.0024% and Lidocaine 1% in Glycerin Mouth Paint 
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.
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 flavoured to please each patient. Keeping the mucosal membranes moist can improve comfort for the patient and minimise irritation and the risk of infection.

Int'l J Pharm Compounding. May/June 2000; 4(3):215
Saliva Substitute for Dry Mouth/Throat 
Click here to access the abstract of this article.

Int'l J Pharm Compounding. Sep/Oct 2000; 4(5):340
Saliva Substitute
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, diarrhoea, 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 syndrome: a randomised, placebo-controlled, fixed-dose, multicenter trial. P92-01 Study Group.
Click here to access the PubMed abstract of this article.

Int'l J Pharm Compounding. Sep/Oct 2000; 4(5):381
Pilocarpine HCl 2-mg Troches 
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.
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.
Click here to access the PubMed abstract of this article.

©Storey Marketing. Used with permission. All rights reserved.






New, Noninvasive Approach for Successfully Treating Pain and Inflammation of TMJ Disorders

A topical gel containing 18% potassium complex, 10% dimethylisosorbide, and 72% aqueous hydroxyethyl cellulose gel was applied and gently rubbed onto the facial skin over the painful TMJ, muscles of mastication, and myofacial area. Complete pain relief occurred in 45 of 54 patients in this study within 5 minutes of the first application of the gel, and in all 54 patients after the third day of twice daily application of the treatment gel.

J Oral Implantol. 2007;33(6):365-70. 
A new, noninvasive approach for successfully treating the pain and inflammation of TMJ disorders.
Click here to read the PubMed abstract of this article.

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.
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.
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.
Click here to access the PubMed abstract of this article.

©Storey Marketing. Used with permission. All rights reserved.

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.

Some patients and dentists prefer to use electrolyte lollipops.

Dent Today. 1991 Dec;10(9):68-71
The gagging patient: a method for success.
Click here to access the PubMed abstract of this article.

©Storey Marketing. Used with permission. All rights reserved.

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.

©Storey Marketing. Used with permission. All rights reserved.

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.

J Int Acad Periodontol. 2000 Jul;2(3):64-70 
Clinical evaluation of subgingival application of metronidazole 25%, and adjunctive therapy.
Click here to access the PubMed abstract of this article.

Vojnosanit Pregl. 2005 Jul-Aug;62(7-8):565-8 
Effects of topical application of metronidazole-containing mucoadhesive lipogel in periodontal pockets.
Click here to access the PubMed abstract of this article.

Minerva Stomatol. 2000 Jan-Feb;49(1-2):59-67 
[Topical treatment of peri-implantitis with metronidazole dental gel 25%. Clinical analysis and microbiological control]
Click here to access the PubMed abstract of this article.

J Clin Periodontol. 1992 Oct;19(9 Pt 2):693-7
Systemic absorption of metronidazole after application of a metronidazole 25% dental gel.
Click here to access the PubMed abstract of this article.

©Storey Marketing. Used with permission. All rights reserved.

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.

Ryan et al. of the Department of Pharmacy, University of California San Diego, La Jolla, CA, sought to determine if an oral ketamine “swish and expectorate” mouthwash was a safe and effective method to alleviate mucositis pain. They concluded that a ketamine mouthwash administered using the “swish and spit” technique may be a viable treatment option in refractory mucositis pain.

J Palliat Med. 2009 Nov;12(11):989-91.
Ketamine mouthwash for mucositis pain. Ryan AJ, Lin F, Atayee RS.
Click here to access the PubMed abstract of this article.  

“Magic mouthwashes” are topical solutions or suspensions prepared to relieve symptoms of various oral pathologies. A study conducted at the Department of Clinical Pharmacy, University of California, San Francisco, described the usage of topical oral solutions in patients experiencing chemotherapy-induced oral mucositis (CIOM), and surveyed the care of oral mucositis provided to patients by clinical oncology pharmacists in institutional settings. The top five ingredients used to compound “magic mouthwash” were reported to be diphenhydramine, viscous lidocaine, magnesium hydroxide/aluminum hydroxide, nystatin and corticosteroids. Most institutions administer the mouthwash every 4 hours or every 6 hours.

J Oncol Pharm Pract. 2005 Dec;11(4):139-43.
Survey of topical oral solutions for the treatment of chemo-induced oral mucositis. Chan A, Ignoffo RJ.
Click here to access the PubMed abstract of this article.  

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.
Click here to access the PubMed abstract of this article.

©Storey Marketing. Used with permission. All rights reserved.

We are dedicated to meeting the unique needs of dental patients, and we welcome your questions and medication problems. Our compounding professionals are problem-solving specialists! Examples of Customized Medications for Dental Care

• Anti-Viral Lip Balms
• Ketamine/Ketoprofen/Gabapentin gel
• Ketoprofen/Cyclobenzaprine topical gel
• Lidocaine/Prilocaine gel in plasticized base
• Mucosal Bandages Oxytetracycline/Hydrocortisone Suspension
• Peruvian Balsam/Eugenol
• Sucralfate Oral Adhesive Paste
• Tranexamic Acid Mouthwash
• Triple-Anesthetic gel - benzocaine/lidocaine/tetracaine ("BLT")
• Pressure Indicating Paste (PIP)

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.

©Storey Marketing. Used with permission. All rights reserved.