Table 5: Anxiolytics and Muscle Relaxant Medications as Adjuvant Pharmacotherapy for Orofacial Pain Formulations Usual Daily Dosage
Anxiolytic Medications
Chlorzoxazone (Lorzone, Parafon Forte)
375, 500, 750 mg tablets
500-750 mg tid-qid
Muscle spasticity
Cyclobenzaprine (Flexeril, generics Carisoprodol (Soma, generics) Metaxalone (Skelaxin, generics) Methocarbamol (Robaxin, generics) Orphenadrine (Norflex, generics) Tizanidine (Zanaflex, generics)
5, 7.5, 10 mg tablets 15, 30 mg ER capsule
5-10 mg tid ER: 15-30 mg once
Muscle spasticity
250, 350 mg tablets
250-350 mg tid-qid
Muscle spasticity
800 mg tablets
800 mg tid-qid
Muscle spasticity
500, 750 mg tablets
1.5 g 4 times/day for 2-3 days, then decrease to 4-4.5 g/day in 3-6 divided doses
Muscle spasticity
100 mg ER tablets
100 mg bid
Muscle spasticity
2, 4, 6 mg capsules 2, 4 mg tablets
4-8 mg tid-qid
Muscle spasticity
ER = extended-release. Note . Adapted from: “Algorithm for Neuropathic Pain Treatment: An Evidence-Based Proposal,” by N. B. Finnerup, M. Otto, H. J. McQuay, T. S. Jensen, & S. H. Sindrup, 2005, Pain, 118(3), 289-305, and “PEER simplified decision aid: neuropathic pain treatment options in primary care, ”by K. Chan, D. Perry, A.J. Lindblad, S. Garrison, J. Falk, J. McCormack, C.S. Korownyk, J. Kirkwood, J. Ton, B. Thomas, S. Moe, N. Dugré, M.R. Kolber & G.M. Allanm 2021, Canadian Family Physician, 67 (5), 347-349.
Scientific evidence from clinical trials is limited regarding these pharmacotherapy choices (Heir et al., 2008; Clark, Padilla and Dionne, 2016). Nearly any drug that can have a local action can be formulated for topical use by a compounding pharmacy. There has been recent interest in using compounded anticonvulsants (gabapentin), antidepressants, NSAIDs, N-methyl-D-aspartate (NMDA) antagonists (dextromethorphan, memantine), opioids, and α 2-adrenergic agonists (clonidine), yet no standardized dosing guidelines are available (Heir et al., 2008; Mena, Dalbah, Levi, Padilla & Enciso, 2020). Indeed, one
clinical case was managed effectively by using a compounded neurosensory topical medication consisting of carbamazepine 4%, lidocaine 1%, ketoprofen 4%, and gabapentin 4% in a pluronic lecithin organogel and an anhydrous gel base (Haribabu, Eliav, & Heir, 2013). Surgical approaches and the use of platelet-rich plasma have also been investigated to eliminate neuropathic pain (Kuffler, et al., 2021). Topical medications from several different drug classes can be very effective in providing local analgesia and can be mixed with mucosal adherent formulations for improved analgesia (Table 6).
Table 6: Topical Medications for Orofacial Pain Anxiolytic Medications Formulations
Usual Daily Dosage
Anxiolytic Medications
Clonidine (Catapres, generics)
Weekly transdermal patches 0.1, 0.2, 0.3 mg/24 hour
0.1 mg/24-hour patch applied once every 7 days and increase by 0.1 mg at 1-week intervals if necessary. Apply a thin film to affected area 2-3 times/ day as needed. Patch: Apply patch to painful area. Patch may remain in place for up to 12 hours in any 24-hour period. No more than 1 patch should be used in a 24-hour period.
Hypertension Pain management
Lidocaine (Lidoderm, generics)
3%, 4%, 5% cream 0.5%, 2%, 4%, 5% topical gel 5% transdermal patch
Topical anesthetic
Diphenhydramine (Benadryl, generics) Benzocaine (Orajel, generics)
12.5 mg/5 mL oral solution Rinse and expectorate 25 mg q4–6h prn for pain.
Antihistamine
10, 15 mg lozenge 5%, 10%, 20% topical (oral) spray 7.5%, 10%, 15%, 18%, 20% topical gel
Oral: Allow 1 lozenge (10-15 mg) to dissolve slowly in mouth; may repeat every 2 hours as needed. Topical (oral) spray: Apply 1 spray to affected area, then wait ≥1 minute and spit; may repeat up to 4 times daily. Topical (oral) gel: Apply thin layer to affected area up to 4 times daily.
Topical anesthetic
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