First correct two prescription-writing points

1. BP should be written as 120/80 mmHg, not mg. This represents controlled blood pressure and is acceptable for routine periodontal surgery.
2. Amlodipine “500 mg” is almost certainly an error. The usual adult dose is 5 mg once daily (sometimes 10 mg), not 500 mg. In a viva, say:
   “I would verify the antihypertensive drug and dose from the patient’s prescription before treatment. I presume this is amlodipine 5 mg OD.”

Viva-ready defense of the prescription

1. Amoxicillin 500 mg + clavulanic acid 125 mg twice daily for 5 days

Why it may be prescribed

• It is a bactericidal beta-lactam antibiotic plus beta-lactamase inhibitor.
• Amoxicillin inhibits bacterial cell-wall synthesis by binding penicillin-binding proteins.
• Clavulanic acid inhibits many bacterial beta-lactamases, protecting amoxicillin from enzymatic degradation.
• It provides broad activity against many oral facultative organisms and anaerobes, including beta-lactamase-producing organisms.
• It may be chosen when the surgery is extensive or contaminated, there is pre-existing infection/suppuration, significant tissue trauma, regenerative material or graft use, acute periodontal abscess, poor plaque control, smoking, immunocompromise, or a specific medical/surgical reason for antibiotic cover.

How to defend the dose

• 500/125 mg every 12 hours is an approved adult dosing regimen for mild-to-moderate susceptible bacterial infections, as shown in the DailyMed product information.
• A 5-day course limits exposure compared with longer courses and is consistent with antibiotic-stewardship principles if an antibiotic is genuinely indicated.
• Advise administration at the start of a meal to reduce gastrointestinal intolerance.

The important examiner-level caveat

Strong viva wording

“This is not a routine prescription for every flap surgery. I would prescribe amoxicillin-clavulanate only after documenting an individual indication such as active infection, extensive grafting or regenerative surgery, gross contamination, systemic compromise, or another clearly defined surgical risk. Controlled hypertension alone is not an indication. If the surgery was uncomplicated and aseptic, chlorhexidine-based plaque control and review may be preferable to routine systemic antibiotic use.”

Safety screening and counseling

• No immediate hypersensitivity to penicillin, amoxicillin, cephalosporins, or previous amoxicillin-clavulanate-associated cholestatic jaundice/hepatitis.
• Renal function if kidney disease is suspected. Dose modification may be needed in significant renal impairment.
• Concomitant warfarin or other anticoagulants, because INR monitoring may be warranted.
• Warn about nausea, diarrhea, candidiasis, rash, and rare severe allergy.
• Stop the medicine and seek urgent help for facial swelling, wheeze, generalized urticaria, or severe/persistent diarrhea.

2. Paracetamol 500 mg twice daily for 5 days

Why it may be prescribed

• It is an analgesic and antipyretic for expected mild-to-moderate postoperative pain after flap surgery.
• It is useful in a hypertensive patient because it does not have the same renal, gastrointestinal, platelet-inhibitory, and blood-pressure concerns as NSAIDs.
• Avoiding or minimizing NSAIDs can be sensible in patients with hypertension, especially when BP control, renal function, cardiovascular risk, or antihypertensive therapy are concerns.

Is 500 mg twice daily reasonable?

• Total dose is 1 g/day, which is conservative.
• It can be defended if the expected pain is mild and the aim is to provide basic analgesia with a wide safety margin.
• However, for postoperative dental pain, it is usually more rational to prescribe it as needed, rather than insist on fixed twice-daily dosing.

Better viva wording

“Paracetamol was selected as first-line analgesia because it controls mild postoperative pain without increasing bleeding tendency or compromising blood-pressure control as NSAIDs may do. A dose of 500 mg twice daily is a conservative regimen. I would individualize it as needed for pain, ensuring that the total daily paracetamol from all sources does not exceed the safe limit.”

Safety points

• Do not combine with other cold/flu or pain products containing paracetamol.
• Avoid excess alcohol.
• Use a lower maximum daily dose in low body weight, chronic alcohol use, malnutrition, or liver disease.
• In many adults, the absolute ceiling is 4 g/day, but a safer routine ceiling is often 3 g/day, particularly if risk factors exist.

3. Pantoprazole 40 mg once daily for 5 days

Why it may be prescribed

• Existing dyspepsia, GERD, gastritis, or peptic-ulcer disease.
• Gastroprotection when an NSAID is prescribed.
• Short-term relief of acid-related upper GI symptoms during multiple-drug therapy.

Examiner-level issue

Strong viva wording

“Pantoprazole 40 mg OD may be justified if the patient has documented acid-peptic disease, reflux symptoms, previous ulcer disease, or if an NSAID is used. However, with paracetamol alone, routine PPI prophylaxis is not essential. I would document the gastrointestinal indication rather than prescribe it automatically.”

Safety points

• Short 5-day use is generally well tolerated.
• Long-term unnecessary PPI use should be avoided.
• It can alter absorption of medicines requiring an acidic gastric pH and may have clinically relevant interactions with selected drugs. These are less relevant in a brief course but medication history should still be reviewed.

4. Chlorhexidine gluconate mouthwash 0.12%, 15 mL twice daily, 30 minutes after brushing

Why it may be prescribed

• During the early healing period, mechanical plaque removal at the surgical site may be restricted.
• Chlorhexidine is a broad-spectrum cationic antiseptic with substantivity. It binds to oral surfaces and is released gradually, maintaining antimicrobial activity.
• At lower concentrations, it is bacteriostatic; at higher concentrations, it causes cell-membrane disruption and is bactericidal.
• It reduces plaque accumulation and gingival inflammation while the flap wound heals.

Why 30 minutes after brushing?

• This is scientifically sound.
• Anionic surfactants in many toothpastes, particularly sodium lauryl sulfate, can reduce chlorhexidine activity.
• Therefore, rinsing at least 30 minutes after brushing helps preserve chlorhexidine substantivity and antimicrobial effect.

How to use

• Measure 15 mL undiluted.
• Rinse gently for 30-60 seconds, then spit out.
• Do not swallow.
• Do not rinse with water immediately afterward.
• Avoid vigorous rinsing in the first postoperative period if it disturbs the surgical site. Follow the surgeon’s specific instructions.

Duration and adverse effects

• Brown staining of teeth, tongue, restorations, and appliances.
• Altered taste sensation.
• Increased calculus formation with prolonged use.
• Rare mucosal irritation or hypersensitivity.

Strong viva wording

“Chlorhexidine 0.12%, 15 mL twice daily, is prescribed as a temporary chemical plaque-control adjunct while brushing of the operated area is limited. The 30-minute interval after toothbrushing prevents inactivation by toothpaste detergents. It should be stopped once effective atraumatic mechanical plaque control is resumed, to minimize staining and other adverse effects.”

Overall viva defense

“The patient has controlled hypertension, with BP 120/80 mmHg, and should continue the correctly verified antihypertensive medication, presumed to be amlodipine 5 mg once daily. The prescription aims to control pain, provide temporary chemical plaque control, and, where a documented surgical or infective indication exists, cover susceptible oral bacteria. Paracetamol is preferred over routine NSAIDs because of a more favorable profile regarding blood pressure, renal function, gastric irritation, and bleeding. Chlorhexidine 0.12% is appropriate during early postoperative healing when brushing at the surgical site is restricted. Pantoprazole should be justified by reflux, dyspepsia, ulcer risk, or NSAID use, rather than given automatically. The antibiotic is the part requiring the strictest indication: controlled hypertension alone does not justify it, and it should not be used routinely after an uncomplicated periodontal flap procedure because antimicrobial stewardship and current evidence do not support routine postoperative systemic antibiotics.”

Concise prescription critique

Suggested references for your MDS viva

1. Botelho J, Lyra P, Nascimento GG, et al. Antibiotics in periodontal treatment: an umbrella review. Front Cell Infect Microbiol. 2025. PMID: 40535546. Available via PubMed.
2. Sanz M, Newman MG, Anderson L, et al. Clinical enhancement of post-periodontal surgical therapy by a 0.12% chlorhexidine gluconate mouthrinse. J Periodontol. 1989;60:570-576. DOI reference.
3. Evaluation of antibiotics after routine periodontal surgery. J Indian Soc Periodontol. Full-text study.
4. U.S. National Library of Medicine. Amoxicillin and clavulanate potassium prescribing information, including adult dosing. DailyMed label.
5. Review of antibiotic use and postoperative plaque control in mucogingival/periodontal surgery. PMC review.