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Three Serious Drug Interactions that Every Dentist Should Know About

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 CONTINUING EDUCATION 2
DRUG INTERACTIONS

Three Serious Drug Interactions that

Every Dentist Should Know About
Elliot V. Hersh, DMD, MS, PhD; and Paul A. Moore, DMD, PhD, MPH

LEARNING OBJECTIVES

Abstract: Patients with complex medical and drug histories are becoming more • identify three serious
drug interactions that
commonplace in dental practice. This article reviews three serious adverse impact dental practice

drug interactions that are well supported by the literature and can impact den- • discuss adverse events

tal practice. Nonsteroidal anti-inflammatory drugs (NSAIDs) inhibit the renal related to drug interac-
tions in certain patients,
excretion of lithium and lead to lithium toxicity. Metronidazole and flucon- as described in cases and

azole inhibit the metabolism of warfarin by blocking cytochrome P-450 2C9 clinical studies

• identify alternative
(CYP-2C9), the major metabolic pathway of warfarin, with the end result being
medications that can be
dramatic increases in patients’ international normalized ratios (INRs) and employed to avoid these
serious drug interactions
potentially fatal bleeding. Propranolol and other nonselective beta-adrenergic
blocking agents can inhibit the vasodilatory effect of epinephrine in dental local
anesthetic solutions, leading to hypertensive reactions and a concomitant reflex bradycardia. It is important
for clinicians to recognize and avoid these serious drug interactions. By doing so, they will provide the safest
and best treatment for their patients.

U
nquestionably, the aging dental patient population of action, an inhibition of prostaglandin synthesis at the site of
is consuming more and more drugs, including a va- surgical trauma, which renders these drugs highly effective in the
riety of psychotropic medications and cardiovascu- treatment of postoperative dental pain.2,3 There are numerous ev-
lar drugs.1 The most common drugs that dentists idence-based, double-blind, placebo-controlled published studies
prescribe or administer include nonsteroidal anti- that demonstrate the overall effectiveness of these drugs after the
inflammatory drugs (NSAIDs) such as ibuprofen and naproxen surgical removal of impacted third molars.4-11 However, in certain
(Table 1), antibiotics and antifungals such as metronidazole (eg, patients, NSAIDs should be avoided or used cautiously because of
Flagyl®) and fluconazole (eg, Diflucan®), and local anesthetics the possibility of precipitating a serious adverse drug interaction.
containing the vasoconstrictor epinephrine (Table 2). What many A comprehensive review of this subject can be found in previous
clinicians do not realize is that these commonly employed drugs in publications.12,13 One such drug is lithium.14
practice can be involved in serious adverse drug interactions with Lithium is a major remedy in the treatment of bipolar depressive
medications patients are taking for a variety of medical conditions. disorder.15 It has a low therapeutic index, which means the differ-
This article will review three of the serious interactions that can ence between effective doses and toxic doses is relatively small.
potentially occur within the practice of dentistry. Therefore, plasma levels of lithium must be carefully monitored
to ensure therapeutic effectiveness while avoiding toxicity.15 The
NSAIDs And Lithium NSAIDs inhibit the renal excretion of lithium and can cause plasma
As illustrated in Table 1, there are a variety of NSAIDs from which lithium to accumulate to toxic levels, potentially leading to renal,
dentists can choose to manage odontogenic and postoperative gastrointestinal, and central nervous toxicity.14-18 Both ibuprofen
pain. These analgesics represent the first line drugs that should 1800 mg/day and naproxen 750 mg/day for 6 days have been dem-
be employed in this situation because of their unique mechanism onstrated to increase previously stable lithium plasma levels, and

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CONTINUING EDUCATION 2 | DRUG INTERACTIONS

TABLE 1 4 to 5 days) should be initiated, and reductions in the lithium dose

may be required.14 An alternative is to avoid NSAID analgesics al-
Common NSAIDs Used to Treat Acute Pain together in lithium-treated patients and prescribe acetaminophen,
or if necessary, an acetaminophen/opioid combination drug such
GENERIC NAME COMMON TRADE NAMES as acetaminophen plus hydrocodone (eg, Vicodin®).
Ibuprofen Advil®, Motrin®, Vicoprofen®,
Combunox®
Metronidazole or Fluconazole in
Naproxen sodium Aleve®, Anaprox® Combination with Warfarin
Diflunisal Dolobid® Metronidazole is highly effective against obligate anaerobic bacte-
Diclofenac Cataflam®, Zipsor® ria associated with periodontal disease, periapical abscesses, and
Ketoprofen Orudis®
peri-implantitis.21-24 Because it has no activity against facultative
anaerobic bacteria, which may be part of a flora mixture inhabiting
Etodolac Lodine®
these infected sites, metronidazole frequently is combined with a
Meloxicam Mobic®
penicillin or with ciprofloxacin.21-23 Fluconazole is an antifungal
Ketorolac Toradol®, SPRIX® agent that is effective in the treatment of mucosal candidiasis and
other candidial infections in the oral cavity.25
Warfarin (eg, Coumadin®) is the most frequently prescribed
TABLE 2 anticoagulant in the world and is employed in preventing myocar-
dial infarctions, pulmonary embolisms, and occlusive strokes in
Local Anesthetics Containing Epinephrine high-risk patients, such as those with atrial fibrillation, heart valve
replacement, and deep venous thrombosis.26,27 Similar to lithium,
GENERIC NAME COMMON TRADE
NAMES warfarin has a low therapeutic index, and monthly monitoring of
2% lidocaine with 1:50,000 or Xylocaine®, Octocaine®, patients’ coagulation status is advised to ensure that plasma levels
1:100,000 epinephrine Lignospan® are in the therapeutic range.12,27 Excessive blood levels of warfarin
4% articaine with 1:100,000 or Septocaine® can lead to internal bleeding, including intracranial bleeding.28
1:200,000 epinephrine Warfarin is mainly metabolized through the intestinal and he-
4% prilocaine with 1:200,000 Citanest® Forte patic cytochrome P-450 system, whose predominant metabolizing
epinephrine isoform is cytochrome P-450 2C9 (CYP 2C9).29 Metronidazole and
0.5% bupivacaine with Marcaine® fluconazole are potent inhibitors of CYP 2C9; thus, they can block
1:200,000 epinephrine warfarin metabolism and subsequently increase blood levels of
warfarin to toxic levels, especially its more potent S(-) isomer.29-31
In a study of eight normal volunteers, pretreatment with met-
the magnitude of this effect varied widely among individuals.16,17 ronidazole 750 mg/day for 1 week significantly increased plasma
Ibuprofen produced a mean increase of 34% (range 12% to 66%), levels and half-lives of even a single dose of warfarin compared
while naproxen produced a mean increase of 16% (range 0% to to taking warfarin alone.32 This was accompanied by a significant
42%). Individual cases of three- to four-fold increases in lithium increase in mean prothrombin times.32 In one case report, a 31-year-
blood levels accompanied by stupor, ataxia, confusion, and renal old woman who had received 6 years of warfarin therapy without a
failure have been reported after the use of ibuprofen 1600 mg/day previous bleeding episode was admitted to a hospital with several
for 1 week to treat shoulder pain.18 A more recent report describes ecchymoses of both legs and obvious swelling and hemorrhage into
a 51-year-old patient with a history of bipolar disorder on lithium the subcutaneous tissue behind her left knee after completing a
therapy presenting to an emergency department with confusion, 10-day course of metronidazole 750 mg/day for a trichomoniasis
dysarthria, abnormal gait, and diarrhea.19 He subsequently needed infection.30 Her prothrombin time was 147 seconds; the normal pro-
to be intubated before being discharged from the hospital. His thrombin time is 17 to 19 seconds. Vitamin K, the antidote for a war-
symptoms started 2 days after his dentist prescribed ibuprofen farin overdose, was given and her condition resolved over 1 week.30
800 mg 3 times daily after extracting an infected molar. His labora- More recently, a 78-year-old woman was started on metronidazole
tory values were significant for elevated lithium levels of 3 mmol/ 250 mg every 8 hours for 5 days, and levofloxacin (Levoquin®) 500
liter (therapeutic range 0.6 mmol/liter to 1 mmol/liter) and mild mg once a day for 6 days for an upper respiratory tract infection.33
renal failure. Another recent report describes a 49-year-old woman The patient did not notify any of the healthcare professionals that
with stable lithium concentrations experiencing lethargy, diarrhea, she was on concomitant warfarin therapy. Her most recent interna-
nausea, vomiting, hypersalivation, tremors, muscle weakness, and tional normalized ratio (INR) reading had been 2.5. Six days after
confusion 3 days after being started on the NSAID meloxicam. Her her clinic visit, the patient was admitted to the hospital for a profuse
serum lithium levels were greater than 5 mmol/liter.20 nosebleed and “an unusual headache,” and a CAT scan revealed she
It is recommended that before prescribing NSAID analgesics had a minor hemorrhagic stroke. Her INR had risen to 8.0. After a
to a patient on lithium therapy, dentists consult with the patient’s 1-week hospital stay, which included the administration of vitamin
psychiatrist. More frequent lithium blood level monitoring (every K and a blood transfusion, she was discharged.33

740 COMPENDIUM June 2015 Volume 36, Number 6

 Cases of cerebral hemorrhage,34 gastrointestinal bleeds,35,36 TABLE 3
intraocular hemorrhage,37,38 and significantly elevated INRs36,39
due to a warfarin–fluconazole interaction have appeared in the The Action of Epinephrine at Various Receptors
literature. In a retrospective cohort study, 22,272 veterans who had
RECEPTOR SUBTYPE RECEPTOR ACTIONS
been on warfarin therapy for at least 1 month were administered
Alpha-1 Adrenergic Vasoconstriction of blood
an antimicrobial agent. Among them, 9.7% of those who received
vessels beneath skin and
fluconazole and 4.9% of those who received metronidazole had mucous membranes
INRs that were greater than 6.0 (normal INRs in anticoagulated
Beta-1 Adrenergic Increased heart rate
patients should be between 2.0 and 3.0).40 Employing US Medicaid Increased contraction force
data, a case-control study of 308,100 warfarin users demonstrated
Beta-2 Adrenergic Bronchodilation
an elevated risk (odds ratio = 2.09) of gastrointestinal bleeding Vasodilation of blood ves-
in warfarin recipients receiving fluconazole compared to those sels in skeletal muscle and
receiving the non-interacting antibiotic cephalexin (Keflex®).41 internal organs
Based on these case reports and clinical studies, the authors
recommend that dentists avoid prescribing metronidazole or flu-
TABLE 4
conazole in patients on concomitant warfarin therapy.

Epinephrine with Propranolol Classification of Beta-Adrenergic Blocking

There is probably no area in dental pharmacology that is more highly Agents with Common Trade Names
debated than the use or avoidance of epinephrine-containing local
NONSELECTIVE CARDIOSELECTIVE
anesthetics in certain medically complex patient populations, includ- BETA-BLOCKERS BETA-BLOCKERS
ing those taking potentially interacting drugs.12,42-47 In reality, case
Propranolol (Inderal®) Atenolol (Tenormin®)
reports describing adverse drug interactions between vasoconstric-
tors in dental local anesthetic solutions and potential interacting Nadolol (Corgard®) Metoprolol (Lopressor®)
drugs are extremely rare, partly because epinephrine is currently Timolol (Blocadren®) Acebutolol (Sectral®)
by far the vasoconstrictor agent most widely used with local an- Sotalol (Betapace®) Betaxolol (Kerlone®)
esthetics in dentistry. While epinephrine has alpha-1 adrenergic
vasoconstrictive effects on some vascular beds—most notably under
the skin and mucous membranes—it also has vasodilatory effects on case, a patient receiving 13 ml of a 1:200,000 epinephrine solution
other vascular beds that contain predominantly beta-2 adrenergic went into cardiac arrest and had to be resuscitated with emergency
receptors, such as those in skeletal muscle, resulting in vasodilation48 treatment, including defibrillation.52
(Table 3). This opposing vasodilatory property of epinephrine limits There is only a single case report in the dental literature in which
the potential pressor effects of the drug compared to other agents a patient, a 32-year-old woman, taking daily propranolol for hy-
like levonordefrin and norepinephrine, which have less, and in the pertension and dysrhythmias received 1.5 cartridges of 2% mepi-
case of norepinephrine, almost no beta-2 adrenergic activity.44,47,49 vacaine plus 1:20,000 levonordefrin (a vasoconstrictor chemically
Beta adrenergic–blocking drugs, also known as beta-blockers, related to epinephrine).53 Her systolic and diastolic blood pressures
are widely used in the treatment of hypertension, angina, cardiac rose by 40 mm Hg and 15 mm Hg, respectively. When two cartridges
arrhythmias, and migraine headaches.50 They are classified into of 3% mepivacaine plain were used on a subsequent visit, her blood
two groups: nonselective beta-blockers that block both beta-1 and pressure remained stable.
beta-2 receptors; and cardioselective beta-blockers, which only The theoretical basis of this serious adverse drug reaction be-
block beta-1 receptors (Table 4). The cardioselective beta-blockers tween propranolol and epinephrine is that the former blocks the
are more widely prescribed today because their lack of beta-2 ad- beta-2 vasodilatory effects of epinephrine, leaving the alpha-1
renergic–blocking activity limits the bronchoconstrictive effects vasoconstrictive effects functioning unopposed, leading to hy-
occasionally seen with nonselective beta-blockers.50 However, the pertension with a concomitant reflex bradycardia.42,43,47 One of
nonselective beta-blocker propranolol is still widely prescribed.51 the most compelling studies supporting the adverse interaction
A case series describing severe hypertensive reactions in six pa- between propranolol and epinephrine is illustrated in Figure 1 and
tients on chronic propranolol therapy receiving lidocaine with Figure 2.54 Five patients being treated for long-standing severe hy-
epinephrine for facial plastic surgery procedures has appeared in pertension with either the nonselective beta-adrenergic blocking
the literature.52 In two of the cases, the patients had been adminis- agent propranolol or the cardioselective beta-adrenergic blocking
tered 10 ml and 12 ml of a 1% lidocaine plus 1:100,000 epinephrine agent metoprolol took their usual morning dose of their respec-
solution, respectively. This translates into the amount of epineph- tive beta-adrenergic blocking agent 2 hours prior to undergoing a
rine in approximately six and seven 1.7-ml dental local anesthetic vasopressor challenge using slow epinephrine infusions of various
cartridges. Their blood pressures rose from normal levels (120/80 doses over 8 minutes. After the completion of the first session,
and 110/70 mm Hg) to acutely hypertensive levels (200/100 and these patients were crossed over to the alternative treatment for
190/110 mm Hg), with a concomitant reflex bradycardia. In a third at least 4 weeks, and the epinephrine challenge was administered

www.compendiumlive.com June 2015 COMPENDIUM 741

CONTINUING EDUCATION 2 | DRUG INTERACTIONS

again. As shown in Figure 1, following the slow infusion of 16 μg nonselective beta-adrenergic blocking agent pindolol, small (8
(2 μg/min) of epinephrine, which is slightly less than that found mm Hg to 9 mm Hg) but significant (P < 0.05) increases in systolic
in a single 1.7-mL 1:100,000 epinephrine dental cartridge (17 μg and diastolic blood pressure and peripheral vascular resistance,
or 0.017 mg),47 the mean increase in systolic blood pressure was with corresponding decreases in heart rate, were observed after
about 15 mm Hg in the propranolol group and only 5 mm Hg in the administration of two intraoral injections of 2% lidocaine
the metoprolol group. As shown in Figure 2, the differences in plus 1:80,000 epinephrine (45 μg or 0.045 mg epinephrine total).
diastolic blood pressure following the 16-μg epinephrine infu- When these same individuals were not pretreated with pindolol,
sion was even more pronounced, increasing only 2 mm Hg in the the administration of the same dose of local anesthetic solution
metoprolol group but 14 mm Hg in the propranolol group. This induced small decreases in systolic and diastolic blood pressure and
difference reached the level of statistical significance (P < 0.05). peripheral vascular resistance.58 Similar results were reported in
When 32 μg of epinephrine was slowly infused, an amount slightly dental patients with cardiovascular disease on nonselective beta-
less than two 1.7-mL cartridges of a 1:100,000 solution (34 μg or blocker therapy who received a single cartridge of 2% lidocaine
0.034 mg),47 the metoprolol group exhibited a 10-mm Hg increase with 1:80,000 epinephrine (22.5 μg or 0.0225 mg epinephrine).59
in mean systolic blood pressure, whereas the propranolol group Based on the case reports in the plastic surgery literature and
exhibited a mean systolic blood pressure increase of 33 mm Hg the results of the clinical studies presented above, the following
(P < 0.05). Diastolic blood pressure remained unchanged in the recommendations are made. In patients requiring simple restor-
metoprolol group but increased 21 mm Hg in the propranolol ative dentistry procedures who are on propranolol or other non-
group (P < 0.05).54 Other intravenous infusion studies have re- selective beta-adrenergic blocking agents, complete avoidance
ported similar pressor responses when epinephrine was admin- of local anesthetic solutions containing epinephrine, such as em-
istered to patients on propranolol and other nonselective beta- ploying 3% mepivacaine or 4% prilocaine plain, appears prudent.
blockers.55-57 Although one can argue that intravenous infusions In patients requiring hemostasis for dental surgical procedures
do not resemble typical submucosal dental injections, inadvertent or a longer duration of action, an absolute maximum of 0.034
intravascular injections do occur in dental practice, with injection mg of epinephrine (two cartridges of a 1:100,000 solution or four
speeds at least eight times more rapid (one cartridge per minute) cartridges of a 1:200,000) solution is advised. Proper aspirating
than the infusion rates in the studies discussed here.47 technique is mandatory to avoid inadvertent intravascular injec-
There are two studies in the literature where individuals on tions, and very slow injections rates are recommended. Before
nonselective beta-adrenergic blocking agents received dental administering additional cartridges of local anesthetic solution,
injections of lidocaine with epinephrine.58,59 In one study, when blood pressure and heart rate should be taken to ensure that
normal volunteers were pretreated with a single oral dose of the these vital signs remain stable. The use of 1:50,000 epinephrine

FIG 1. FIG 2.

Systolic Blood Pressure Changes Diastolic Blood Pressure Changes

190 * 130
M = metoprolol M = metoprolol
180 125 *
P = propranolol P = propranolol
120
170
*
115
160
110
150
105
140 100

130 95

120 90
M P M P M P M P M P M P
Baseline 16 μg 32 μg Baseline 16 μg 32 μg

Fig 1. Systolic blood pressure recordings (mean ± SEM) at baseline and Fig 2. Diastolic blood pressure recordings (mean ± SEM) at baseline and
at the end of 16-μg and 32-μg epinephrine infusions in five hypertensive at the end of 16-μg and 32-μg epinephrine infusions in five hypertensive
patients on long-term metoprolol or propranolol therapy. The study was patients on long-term metoprolol or propranolol therapy. The study was
a crossover design. (* P < 0.05 versus metoprolol pretreatment.) a crossover design. (* P < 0.05 versus metoprolol pretreatment.)
(Data from Houben H, Thien T, van’t Laar A. Effect of low-dose epinephrine infusion (Data from Houben H, Thien T, van’t Laar A. Effect of low-dose epinephrine infusion
on hemodynamics after selective and nonselective beta-blockade in hypertension. on hemodynamics after selective and nonselective beta-blockade in hypertension.
Clin Pharmacol Ther. 1982;31[6]:685-690. Redrawn and used with permission from Clin Pharmacol Ther. 1982;31[6]:685-690. Redrawn and used with permission from
Hersh EV, Giannakopoulos H. Beta-adrenergic blocking agents and dental vasocon- Hersh EV, Giannakopoulos H. Beta-adrenergic blocking agents and dental vasocon-
strictors. Dent Clin North Am. 2010;54[4]:687-696.) strictors. Dent Clin North Am. 2010;54[4]:687-696.)

742 COMPENDIUM June 2015 Volume 36, Number 6

and the use of epinephrine-impregnated gingival retraction cord 6. Kiersch TA, Halladay SC, Hormel PC. A single-dose, double-blind
that contains 0.5 mg to 1 mg of racemic epinephrine per 2.5 cm,60 comparison of naproxen sodium, acetaminophen, and placebo in post-
operative dental pain. Clin Ther. 1994;16(3):394-404.
should be absolutely avoided.47,61
7. Levin LM, Cooper SA, Betts NJ, et al. Ketoprofen dental pain study. J
Clin Dent. 1997;8(4):103-106.
Conclusion 8. Hersh EV, Levin LM, Cooper SA, et al. Conventional and extended-re-
With an aging dental patient population using an increasing amount lease etodolac in postsurgical dental pain. Clin Ther. 1999;21(8):1333-1342.
of drugs, practitioners must be cognizant of adverse drug interac- 9. Hersh EV, Levin LM, Cooper SA, et al. Ibuprofen liquigel for oral
surgery pain. Clin Ther. 2000;22(11):1306-1318.
tions that can potentially endanger their patients. Three such se-
10. Zuniga JR, Noveck RJ, Schmidt WK, et al. Onset of action of diclof-
rious interactions have been reviewed. NSAIDS, which are highly enac potassium liquid-filled capsules in dental surgery patients. Curr
effective in the treatment of postoperative pain, should be avoided Med Res Opin. 2011;27(9):1733-1739.
or used cautiously in lithium-treated patients. Prescribing either 11. He A, Hersh EV. A review of intranasal ketorolac tromethamine
metronidazole, an effective drug against anaerobic bacteria, or the for the short-term management of moderate to moderately severe
pain that requires analgesia at the opioid level. Curr Med Res Opin.
antifungal agent fluconazole should be avoided in patients who are
2012;28(12):1873-1880.
on concomitant warfarin therapy. Finally, for patients on proprano- 12. Hersh EV, Moore PA. Adverse drug interactions in dentistry. Peri-
lol, epinephrine-containing local anesthetics should be avoided in odontol 2000. 2008;46:109-142.
patients undergoing restorative procedures of short duration and 13. Hersh EV, Pinto A, Moore PA. Adverse drug interactions involv-
used cautiously (no more than 0.034 mg) in patients requiring ing common prescription and over-the-counter analgesics. Clin Ther.
2007;29(suppl):2477-2497.
hemostasis or longer duration dental procedures.
14. Ragheb M. The clinical significance of lithium-nonsteroidal anti-inflam-
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DISCLOSURE 15. Lewis VA. Psychopharmacology: antipsychotic and antidepressant
drugs. In: Yagiela JA, Dowd FJ, Johnson BS, et al, eds. Pharmacology
Within the past five years, Dr. Moore has served as medical director and/ and Therapeutics for Dentistry. 6th ed. St. Louis, MO: Mosby Elsevier;
or a research consultant to several pharmaceutical companies market- 2011:162-187.
ing local anesthetic products, including DENTSPLY Pharmaceutical
16. Ragheb M. Ibuprofen can increase serum lithium level in lithium-
Division, Kodak Dental Systems, Septodont USA, St. Renatus, and
Novocol of Canada Inc.  His consultations have involved pharmaco- treated patients. J Clin Psychiatry. 1987;48(4):161-163.
vigilance of marketed products as well as protocol development of new 17. Ragheb M, Powell AL. Lithium interaction with sulindac and
anesthetics for dentistry.  Dr. Hersh had no disclosures to report. naproxen. J Clin Psychopharmacol. 1986;6(3):150-154.
18. Khan IH. Lithium and non-steroidal anti-inflammatory drugs. BMJ.
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ABOUT THE AUTHORS
19. Hassan S, Khalid F, Alirhayim Z, Amer S. Lithium toxicity in the set-
Elliot V. Hersh, DMD, MS, PhD ting of nonsteroidal anti-inflammatory medications. Case Rep Nephrol.
Professor, Pharmacology, Department of Oral Surgery and Pharmacology, School of 2013;2013:839796.
Dental Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 20. Chen L, Pym H. Rapid onset of neurological symptoms and lithium
toxicity on starting meloxicam. Aust N Z J Psychiatry. 2010;44(1):95.
Paul A. Moore, DMD, PhD, MPH 21. Ciancio SG, van Winkelhoff AJ. Antibiotics in periodontal therapy.
Professor, Pharmacology and Dental Public Health, Departments of Dental In: Newman MG, van Winkelhoff AJ, eds. Antibiotic and Antimicrobial
Anesthesiology and Dental Public Health, School of Dental Medicine, University of Use in Dental Practice. 2nd ed. Chicago, IL: Quintessence Publishing;
Pittsburgh, Pittsburgh, Pennsylvania 2001:113-126.
22. Baumgartner JC. Antibiotics in endodontic therapy. In: Newman
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[email protected]. Practice. 2nd ed. Chicago, IL: Quintessence Publishing; 2001:143-155.
23. Peterson LJ. Antibiotics for oral and maxillofacial infections. In: New-
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744 COMPENDIUM June 2015 Volume 36, Number 6

 CONTINUING EDUCATION 2
QUIZ

Three Serious Drug Interactions that Every Dentist Should Know About
Elliot V. Hersh, DMD, MS, PhD; and Paul A. Moore, DMD, PhD, MPH

This article provides 2 hours of CE credit from AEGIS Publications, LLC. Record your answers on the enclosed Answer Form or submit them on a
separate sheet of paper. You may also phone your answers in to 877-423-4471 or fax them to (215) 504-1502 or log on to compendiumce.com/go/1512.
Be sure to include your name, address, telephone number, and last 4 digits of your Social Security number.

Please complete Answer Form on page XXX, including your name and payment information.
You can also take this course online at compendiumce.com/go/1512.

1. Lithium is a major remedy in the treatment of: 6. The antidote for a warfarin overdose is:
A. atrial fibrillation. A. naloxone.
B. bipolar depressive order. B. vitamin K.
C. hypertension. C. ibuprofen.
D. anxiety. D. lidocaine.

2. Cases of increases in lithium blood levels accompanied by stupor, 7. 

For certain medically complex patients, perhaps no area in
ataxia, confusion, and renal failure have been reported after the dental pharmacology is more debated than the use or avoidance
use of: of local anesthetics containing:
A. ibuprofen. A. ketorolac.
B. penicillin. B. fluconazole.
C. diazepam. C. epinephrine.
D. hydrocodone. D. ibuprofen.

3.  Fluconazole is an antifungal agent that is effective in the 8. 

Beta adrenergic–blocking drugs, also known as beta-blockers,
treatment of: are widely used in the treatment of:
A. anaerobic bacterial infections. A. hypertension.
B. aerobic bacterial infections. B. angina.
C. facultative anaerobic bacterial infections. C. migraine headaches.
D. m
 ucosal candidiasis and other candidial infections in the D. all of the above
oral cavity.
9. 
Theoretically, propranolol blocks the beta-2 vasodilatory effects
4. Warfarin is employed in high-risk patients, including those with: of epinephrine, leaving the alpha-1 vasoconstrictive effects
A. atrial fibrillation. functioning unopposed, which leads to:
B. heart valve replacement. A. angioedema.
C. deep venous thrombosis. B. stomach ulcers.
D. all of the above C. hypertension.
D. tachycardia.
5. 
As potent inhibitors of CYP 2C9, metronidazole and fluconazole
can block the metabolism of: 10. 
In patients requiring hemostasis for dental surgical procedures
A. warfarin. who are on propranolol, a maximum of how much epinephrine is
B. hydrocodone. advised?
C. naproxen. A. 0.034 mg (34 μg)
D. none of the above B. 0.054 mg (54 μg)
C. 0.068 mg (68 μg)
D. 0.108 mg (108 μg)

Course is valid from 6/1/2015 to 6/30/2018 Participants

must attain a score of 70% on each quiz to receive credit. Par-
AEGIS Publications, LLC, is an ADA CERP Recognized Approved PACE Program Provider
ticipants receiving a failing grade on any exam will be notified FAGD/MAGD Credit
Provider. ADA CERP is a service of the American Dental
and permitted to take one re-examination. Participants will Association to assist dental professionals in identifying qual- Approval does not imply acceptance
ity providers of continuing dental education. ADA CERP does by a state or provincial board of
receive an annual report documenting their accumulated not approve or endorse individual courses or instructors, nor
dentistry or AGD endorsement
credits, and are urged to contact their own state registry does it imply acceptance of credit hours by boards of den-
tistry. Concerns or complaints about a CE provider may be Program Approval for 1/1/2013 to 12/31/2016
boards for special CE requirements. directed to the provider or to ADA CERP at www.ada.org/cerp.
Continuing Education
Provider ID# 209722

www.compendiumlive.com June 2015 COMPENDIUM 745

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