Beavercreek, Ohio

The practice of orthodontics often entails the use of various prescription medications to facilitate treatment. The treatment of temporomandibular disorders provides further indications for chemical adjuncts to therapy. Due to the wide range of pharmaceuticals on the market today, a concise summary of some of the more common medicines used in orthodontic and temporomandibular treatment may be useful to many practitioners.

PAIN MEDICATION

The most common medications used in the orthodontic arena are presumably the nonsteroidal anti-inflammatory drugs (NSAIDS); particularly aspirin, acetaminophen and ibuprofen. These are classified as peripherally acting (nonopioid) analgesics. They function by inhibition of the cyclooxygenase enzyme system which results in the formation of prostaglandins and other inflammatory products. All of these medications exhibit analgesic, antipyretic and anti-inflammatory properties. Little more information regarding these drugs is deemed necessary at this time, with the exception of the following notes: Aspirin has a proven track record but also has the undesirable side effects of gastric irritation and increased bleeding tendencies. Acetaminophen has less side effects but can be more destructive in an overdose situation due to hepatotoxicity. Acetaminophen has also been suggested as having less anti-inflammatory properties. Ibuprofen is not without side effects, particularly gastrointestinal disturbance, but is the drug of choice in our office for orthodontic and temporomandibular discomfort. A recent study comparing aspirin and ibuprofen in patients undergoing orthodontic tooth movement demonstrated better analgesia with ibuprofen¹. In other comparisons, aspirin and acetaminophen have performed similarly whereas ibuprofen appears to function better than aspirin, codeine or a combination of the two.

Prostaglandins exhibit an important role as mediators of the inflammatory response that allows orthodontic tooth movement. Because NSAIDS inhibit prostaglandin synthesis, their utility during orthodontic treatment has been questioned due to potential deceleration of tooth movement. Various studies have been published which indicate that NSAIDS do² and do not³ delay treatment for this reason. Our belief is that the positive effects of pain reduction outweigh any limitations in tooth movement for at least two reasons:

1. NSAIDS are only used at certain times during treatment and
2. 2. since teeth definitely move during their administration, prostaglandins must not be the only mediators of bone resorption.

The following is a review of some medications deemed useful for certain situations that may arise in orthodontic and TMD therapy:

Feldene®, generic name piroxicam, is another NSAID. It is specifically indicated for short and long-term use in treatment of osteoarthritis and rheumatoid arthritis. For this reason it can be used in treatment of TMD when inflammation of the joint itself is suspected. Feldene is assumed to work via inhibition of prostaglandin synthesis, and thus exhibits anti-inflammatory, analgesic and antipyretic properties. This drug, when taken as a daily 20mg dose, requires approximately two weeks of use before judgment should be made regarding its effectiveness in any given patient. It is supplied in 10 and 20mg capsules. No dosage has been recommended for children. An example prescription for a TMD patient would be:

Feldene 20mg

Dispense thirty (30) capsules

Sig: Take 1 capsule per day as

needed for pain.

Tylenol® with codeine (acetaminophen with codeine phosphate) is indicated for moderate to severe pain. As a Schedule III narcotic, this medication is used only for short-term relief of acute orthodontic or TMJ pain, most often in an emergency situation. Schedule III narcotics exhibit a moderate to low dependence liability. Codeine functions on the central as opposed to peripheral nervous system and can thus have a greater impact on the psychological aspects of pain. These central effects contraindicate the use of this medication in patients with head injuries, acute abdominal problems, and in the elderly. Tylenol with codeine is supplied as tablets containing 300mg of acetaminophen and 15mg of codeine (Tylenol with codeine #2), 30mg codeine (Tylenol with codeine #3) or 60mg codeine (Tylenol with codeine #4). An elixir is also available which contains 120mg of acetaminophen and 12mg of codeine per 5ml. All patients should be reminded that the maximum daily adult dose of codeine is 360mg. A typical prescription for a patient in acute distress would be :

Tylenol with Codeine #3

Dispense thirty (30) tablets

Sig: Take 1 or 2 tablets every 4 hours as needed for pain.

For a child (aged 7 to 12 years) a prescription may appear as:

Tylenol with Codeine elixir

Dispense 360ml

Sig: Take 10ml (2 tsp) 3 to 4 times daily as needed for pain.

Flexeril 10mg

Dispense thirty (30) tablets

Sig: Take one tablet 3 times a day.

Elavil®, generically know as amitriptyline, is also referred to as a TCA or tricyclic antidepressant. Used most often for affective disorders, Elavil has the additional distinction of reducing parafunctional activity in patients who exhibit nocturnal bruxism. The exact mechanism of Elavil is unknown, but it does inhibit reuptake of norepinephrine and serotonin to produce its effects which include sedation. Elavil has proven effective in the treatment of chronic orofacial pain, migraine, fibromyalgia, psychogenic problems and bruxism⁴. This drug is an excellent initial medication for TMD patients refractory to splint therapy who appear stressed or know that they tend to clench or grind their teeth in their sleep. Care is taken to assure the patient that their mental status is not under question by this prescription, although this drug is for depression at higher doses, it has different effects at lower doses. The phrase "for bruxism" is added to the notation to reinforce this notion to the patient, pharmacist, and all others who would see the prescription.

Elavil should not be given with MAO inhibitors. (Like Flexeril, Elavil should not be administered for 14 days after an MAO inhibitor). Elavil should also be avoided in cardiovascular problems, hyperthyroidism, and children under 12. Alcohol is contraindicated for these patients. Although available in a wide range of doses (up to 150mg per tablet), the 10mg dose seems most suited for TMD purposes. The dose is increased as needed to up to 40mg at bedtime to titrate to the desired effect. Patients who notice lethargy in the morning may take their dose earlier in the evening to try to offset this side effect. Some patients have also noted weight gain as a side effect. A typical prescription for this medication would be:

Elavil 10mg

Dispense forty (40) tablets

Sig: Take 1 or 2 tablets at bedtime for bruxism.

Valium® (diazepam) is a benzodiazepine derivative used often for the treatment of anxiety disorders. Valium has the additional effect of relieving skeletal muscle spasm caused by muscle and joint inflammation. Valium is occasionally utilized in our office for TMD patients who present (usually as an emergency visit) with acute closed lock and accompanying anxiety. After examination, our regimen is for the patient to take 5mg that evening before bed and another 5mg prior to their return appointment the following morning. Due to the side effects of drowsiness and ataxia, the patient is to be driven to the appointment by an accompanying adult. We have found that this usually allows the symptoms to be reduced significantly for adequate records and splint impressions as needed. As a Schedule IV narcotic, Valium has minor abuse potential. We often prescribe a few extra tablets for the patient to use before appointments with their general dentist if the patient is to remain open for an extended period of time. This can prevent exacerbations of the original problem. A prescription for Valium as employed by our office would be:

Valium 5mg

Dispense five (5) tablets

Sig: Take 1 tablet at bedtime prior to, and 1 tablet fifteen minutes before the next appointment.

OTHER MEDICATION

Mycostatin® (nystatin) ointment is an antifungal (not antibacterial) antibiotic which is effective in treating angular cheilitis and other oral/cutaneous mycotic infections which include those from Candid albicans. Provided in ointment or cream form, this medicament functions by increasing fungal membrane permeability. During orthodontic treatment, some patients develop chronic and painful irritations at the corners of their mouth. While this may be caused or exacerbated by the use of intraoral elastics, headgear facebows, and other physical irritants, Mycostatin is a virtually nontoxic and non-sensitizing agent if fungal infection is suspected. A prescription would be:

Mycostatin 100,000 USP ointment

Dispense one 15gm tube

Sig: Apply to corners of mouth twice a day until healed. Not for ingestion.

Zovirax® (acyclovir) ointment is an antiviral medication which can be prescribed for recurrent outbreaks of herpes labialis. The drug interferes with viral enzyme activity to inhibit viral DNA replication. The net benefit for the patient appears to be through reduction of viral shedding time: by no means a cure, but at least an attempt to reduce the infectious period. Administration should begin as soon as possible after initial onset of symptoms and diagnosis. This drug has its best efficacy by oral administration in the immune-compromised, but topical application seems more prudent in this clinical scenario. Most patients will appreciate any efforts on your part to help relieve them of the manifestations of the malady. Patients should wear a rubber glove or use a cotton swab to prevent auto-inoculation. A typical prescription would be:

Zovirax 5% ointment

Dispense one 15gm tube

Sig: Apply with rubber glove or

cotton swab to affected area 6 times per day until healed.

It is hoped that this review will make some practitioners more comfortable when prescribing certain medications as indicated. Of course, this summary is by no means comprehensive. For example, TMD patients on numerous medications have potential for synergistic and antagonistic interactions with any drugs added to their regimen. If there are any misgivings or uncertainties about prescribing a given medication, a consultation with the patient’s physician and/or the Physician’s Desk Reference is certainly in order.

The Cost of Comfort

Due to the wide range of prices for pharmaceuticals, certain medications may be cost prohibitive to patients or doctors based on the severity of the symptoms treated. The following prices were quoted from a pharmacy in a national chain store in February of 1996. (Generic prices are obviously more affordable for the patient paying out-of-pocket.)