F T ra n sf o F T ra n sf o

PD rm PD rm
Y Y
Y

Y
er

er
4/14/2011
ABB

ABB
y

y
bu

bu
2.0

2.0
to

to
re

re
he

he
k

k
lic

lic
C

C
w om w om
w

w
w. w.
A B B Y Y.c A B B Y Y.c

Drug in Dentistry
• Giving drug is very common in dentistry
• Allowed according to the Dental Act
Drugs in Oral Medicine • Must know what are :
– Indication of giving drug
– Age of patient
mms omop
omop//usim/3/11
usim/3/11 – Medical and drug history
– Allergies
– Contraindication and side effect
• Required by law to know all the information
above before giving drug

Drug in Dentistry Routine Drug in Dentistry

• Drug used routinely in dentistry/general • General use

and specific therapeutic measures – Pain control
• Local anaesthetic agents, analgesic, etc.
• Drug used by patient
– Local and systemic infection control
• Drug being abused by user • Anti microbial agent etc
– Supportive care
• Dental filling material (amalgam, retraction cord
etc)
• Latex glove

Specific Drug in Dentistry

• Successful use of medications depends
• Specific therapeutic upon:
– Ulcers and mucositis – An appropriate diagnosis
– Facial pain – Desirable treatment outcome
– Fungal and Viral infection – Knowledge of whether treatment aimed at
– Allergic reaction management of a chronic disease or
– Xerostomia enhanced resolution of a short term condition
– White lesion and leukoplakia
– etc

1
 F T ra n sf o F T ra n sf o
PD rm PD rm
Y Y
Y

Y
er

er
4/14/2011
ABB

ABB
y

y
bu

bu
2.0

2.0
to

to
re

re
he

he
k

k
lic

lic
C

C
w om w om
w

w
w. w.
A B B Y Y.c A B B Y Y.c

General Rules
Writing Prescriptions
Rx: Drug Name (can be generic) Unit Dose • Write Legibly!!
(ex: Pen V
V--K 500 mg, Elixer, Sol’n) • Remember your audience (Generally non-
non-
docs) this will improve compliance.
Disp: # of pills, milliliters (ml), mg
• Preferable to order specific hourly dosage time
Directions for use: od, bds, qid, prn pain, till gone; topical, (q12h vs. bid, q8h vs. tid, etc.)
oral
• Specify # of pills to take each dose
Refills__ Signature • Prescribe an endpoint. (prn pain, till gone)

Prescribing Prescribing
• Must write : • Hospital/ward drug
– Patient’s name – Special form and request, see hospital protocol
– Name of drug • Children and elderly must altered dose
according to the drug information sheet
– Date given
– Dosage
• Ignorance “tak tahu/ don’t remember” is not
• Must write clearly and given appropriate applicable in court. As a doctor you must know.
advise on taking the medication eg. • Sleep with drug formulary rather than sleep with
Oral,topical, PA etc other things

• Antibiotics
– Organic substances produced by
Antibiotic Use In Dentistry microorganisms that have the ability to
destroy or inhibit the growth of bacteria
and other microorganisms.

2
 F T ra n sf o F T ra n sf o
PD rm PD rm
Y Y
Y

Y
er

er
4/14/2011
ABB

ABB
y

y
bu

bu
2.0

2.0
to

to
re

re
he

he
k

k
lic

lic
C

C
w om w om
w

w
w. w.
A B B Y Y.c A B B Y Y.c

-Two types – Adverse reactions

• Bactericidal • Most likely group for an allergic reaction
– Directly kills the infecting organism • Creation of a super infection
– Peniclillin
• Bacteristatic – Overgrowth in the body of other
– Inhibit the production of the bacteria by interfering with their microorganisms while on prolonged antibiotic
metabolic process treatment
– Tetracycline and erythromycin
-Use is based on – Combining different types of antibiotics at
• A clear need of antibiotic treatment the same time is not recommend.
• No allergies or hypersensitivity to antibiotic – Make birth control pills ineffective for the
• Selection is appropriate to combat that specific month that the patient is using antibiotics
microorganism
• Knowledge of side effects

Antibiotic can be used as: Antibiotic Strategies

• Prophylaxis or • Cardinal Rules:

– 1) Use the right drug.
• Treatment – 2) Use the right dose.
– 3) Use the correct dosing schedule.
– 4) Correct duration.
• Hard and Fast—
Fast—Especially early.
• Use a loading dose to rapidly achieve
therapeutic blood levels.
• Avoid combinations of bacteriostatic and
bacteriocidal drugs.

Considerations
Discussion: Antibiotic Choice
• Gram Positive?
• Gram Negative?
• Narrow Spectrum?
• Mixed Infection?
• Extended/Broad Spectrum?
• Anaerobes?
• Designer Antibiotics?
• Anaerobes? Consider if the infection is
present > 3days or if no improvement.

3
 F T ra n sf o F T ra n sf o
PD rm PD rm
Y Y
Y

Y
er

er
4/14/2011
ABB

ABB
y

y
bu

bu
2.0

2.0
to

to
re

re
he

he
k

k
lic

lic
C

C
w om w om
w

w
w. w.
A B B Y Y.c A B B Y Y.c

Narrow Spectrum Antibiotics Broad Spectrum Antibiotics

• Specific for the pathogen.
• Fewer disturbances of non-
non-pathogenic
bacteria.
• Fewer side effects.
• Rapid response for sensitive organisms.
• Ex: Pen VK, Pen G, Erythromycin
• Affects both Gram + and Gram – bacteria,
better for mixed infections.
• May give up some effectiveness for Gram
+ to gain effectiveness for Gram -.
• Examples: Amoxicillin, Ampicillin

Common Pathogens
•Necrotic pulp and apical abscesses
–Obligate anaerobic bacteria
•Gram negative rods
–Prevotella & porphyomonas spp.
–Fusobacterium spp.
–Campylobacter rectus
•Gram positive rods
–Eubacterium spp.
–Actinomycetes spp.
•Gram positive cocci
–Peptostreptococcus spp.
–Facultative anaerobic bacteria
•Gram positive cocci
–Strep and Entercoccus spp.
Common Pathogens
• Periodontal Diseases
Gingivitis
Fuso, strep, & actinomycetes
Adult periodontitis
– Bacteroides, porphyomonas,
peptostreptococcus & prevotella
Acute necrotizing ulcerative gingivitis
Spirochetes, prevotella, fuso
– Localized juvenile periodontitis
Actinobacillus

About Resistance
Common Pathogens
• Three main types
– Chromosome mediated
• Spontaneous mutations
• Fungal Infections • Non-major form of drug resistance
• Rarely lead to complete resistance
Candida spp. – Plasmid mediated (conjugation)
Mucorales spp. • VERY important from clinical standpoint
• Mostly gram negs
• Mediate resistance to multiple drugs
• High transfer rate from cell to cell
– Transposon (transduction and transformation)
• Phage mediated
• Clinically important for Gram +

4
 F T ra n sf o F T ra n sf o
PD rm PD rm
Y Y
Y

Y
er

er
4/14/2011
ABB

ABB
y

y
bu

bu
2.0

2.0
to

to
re

re
he

he
k

k
lic

lic
C

C
w om w om
w

w
w. w.
A B B Y Y.c A B B Y Y.c

ß-Lactams
• Natural penicillins
Antibiotic Choices – Pen VK and Pen G
• MOA: Inhibit cell wall synthesis
• Dose: 250-500 mg qid x 7-10 days
• Contraindications:
– Allergies
– Poor renal fxn
• Adverse events: GI upset
• Drug interactions: oral contraceptives

ß-Lactams ß-Lactams
• Natural penicillins • Amino-penicillins
– Pen VK and Pen G – Amoxicillin, ampicillin
• Bactericidal • MOA: Inhibit cell wall synthesis
• Allergic reaction: rare (4 per 100,000) • Dose: 250-500 mg q 8 h x 7-10 days
• Contraindications:
• Spectrum: – Allergies
– Strep, staph, enterococcus, neiseria, treponema, listeria – Poor renal fxn
• Resistance: • Adverse events: GI upset
– Mostly staph (>80%) • Drug interactions: oral contraceptives
• Amoxicillin and clavulanic acid (Augmentin)

ß-Lactams Cephalosporins
• Amino-penicillins • Cephalexin (Keflex)
– Amoxicillin, ampicillin – MOA: Inhibit cell wall synthesis
• Bactericidal – Dose: 250-1000mg q 6 h x 7-10 days
• “ampicillin” rash (4-10%) – Contraindications:
• Spectrum: • Allergies
– Strep, staph, enterococcus, neiseria, treponema, listeria,
E. coli, proteus, H. Flu, shigella, salmonella • Poor renal fxn
• Resistance: – Adverse events: mild GI
– Entero, citro, serratia, proteus vulagris, provedincia, – Drug interactions: probenecid
morganella, pseudomonas aeriginosa, acinetobacter

5
 F T ra n sf o F T ra n sf o
PD rm PD rm
Y Y
Y

Y
er

er
4/14/2011
ABB

ABB
y

y
bu

bu
2.0

2.0
to

to
re

re
he

he
k

k
lic

lic
C

C
w om w om
w

w
w. w.
A B B Y Y.c A B B Y Y.c

Cephalosporins Lincosamides

• Cephalexin (Keflex) • Clindamycin (Cleocin)

– Bactericidal – MOA: binds to the 50S ribosomal subunit and inhibits
protein synthesis
– Spectrum: – Dose: 100-450mg q 6 h x 7-10 days
• Gram + – Precautions:
– Resistance: • Poor hepatic fxn
• Methicillin resistant gram + – Adverse events: GI upset, pseudomembraneous
colitis
– Drug interactions: neuromuscular blocking agents

Lincosamides Macrolides
• Clindamycin • Azithromycin (Zithromax), clarithromycin
– Bactericidal or static depending on (Biaxin)
concentration – MOA: bind to the 23S rRNA in the 50S subunit
ribosome
– Spectrum: – Dose: 250-500 mg/day x 5-10 days
• Gram +, anaerobes, parasites – Precautions :
– Resistance • Poor hepatic fxn
• Enteroccocus – Adverse effects: GI
– Drug interactions: Cytochrome P-450
*Clostridium diff. pseudomembranous colitis!!

Macrolides Tetracyclines
• Azithromycin, clarithromycin • Doxycycline (Vibramycin)
– MOA: inhibit protein synthesis by preventing
– Bactericidal aminoacyl transfer RNA from entering the acceptor
– Spectrum: sites on the ribosome
• Gram +, gram -, anaerobes – Dose: 100mg qd-bid x 7-14 days
– Contraindications:
– Resistance: • pregnancy
• B. fragilis, and strep pneumo – Adverse events: GI
– Drug interactions: anti-epileptics
– Not indicated for Pregnant ladies

6
 F T ra n sf o F T ra n sf o
PD rm PD rm
Y Y
Y

Y
er

er
4/14/2011
ABB

ABB
y

y
bu

bu
2.0

2.0
to

to
re

re
he

he
k

k
lic

lic
C

C
w om w om
w

w
w. w.
A B B Y Y.c A B B Y Y.c

Tetracyclines Nitroimidazoles
• Doxycycline • Metronidazole (Flagyl)
– Bacteriostatic – MOA: reduced intermediate interacts and
– Spectrum: breaks the bacterial or parasitic DNA
• Broad, Gram +, -, anaerobes, aerobes, and – Dose: 250-1000 mg q 6-8 h x 7-10 days
spirochetes – Precautions : poor hepatic fxn
– Resistance: – Drug interactions: warfarin, Li+
• Widespread, cross resistance
– Not indicated for Pregnant ladies
– PHOTO SENSITIVITY!!!

Nitroimidazoles
• Metronidazole
– Bactericidal
– Spectrum:
• Gram - anaerobes Systemic & Topical
– Resistance:
• Rare, H. Pylori?
– Unpleasant metallic taste Some are fungistatic,
while others are fungicidal

Fungal Infection in Humans =

Antifungal Agents
Mycosis
• Polyene antifungal
– bind with sterols in the fungal cell membrane, principally
• Major Types of Mycoses ergosterol. This causes the cell's contents to leak out and
the cell dies. Animal cells contain cholesterol instead of
– superficial ergosterol and so they are much less susceptible.
– cutaneous
– subcutaneous – Nystatin
– Amphotericin B (may be administered
– systemic
liposomally)
– opportunistic – Natamycin
• Symptoms vary from cosmetic to life – Rimocidin
threatening – Filipin
– Pimaricin

7
 F T ra n sf o F T ra n sf o
PD rm PD rm
Y Y
Y

Y
er

er
4/14/2011
ABB

ABB
y

y
bu

bu
2.0

2.0
to

to
re

re
he

he
k

k
lic

lic
C

C
w om w om
w

w
w. w.
A B B Y Y.c A B B Y Y.c

Antifungal Agents Antifungal Agents

• Imidazole and triazole
– inhibit the enzyme cytochrome P450 14 -demethylase. This • The triazoles are newer
enzyme converts lanosterol to ergosterol, and is required in fungal
cell membrane synthesis.
– also block steroid synthesis in humans.
• less toxic
• Imidazoles:
• more effective:
• Miconazole Bifonazole • Fluconazole
• Ketoconazole Butoconazole
• Clotrimazole Econazole • Itraconazole
•
•
Mebendazole
Isoconazole
Fenticonazole
Oxiconazole • Ravuconazole
•
•
Sertaconazole
Thiabendazole
Sulconazole
Tiaconazole
• Posaconazole
• Voriconazole

Antifungals Antifungals
• Nystatin • Clotrimazole (Mycelex), ketoconazole
– MOA: inhibit cell wall synthesis (Nizoral), fluconazole (Diflucan)
– Dose: 5 ml swish and swallow q 4 h x 10-14 d – MOA: inhibit cell wall synthesis
– GI upset – Dose: 200-800 mg qd x up to 12 months
– Drug interactions: minor – GI upset
– Drug interactions: major p-450 enzyme
inhibitor, interactions with many drugs

Antiviral

• Acyclovir
acycolvir cream 5% apply to lips 5x daily primary herpetic
gingivostomatitis
herpes labialis
ointment 3% zoster of ophthalmic div

Ayclovir tablets 200 mg 1 tab 5 x daily for 5/7 primary or recurrent

Zovirax intraoral hereps
baby 5 mg/kg every 8 hrs herpes zoster

8
 F T ra n sf o F T ra n sf o
PD rm PD rm
Y Y
Y

Y
er

er
4/14/2011
ABB

ABB
y

y
bu

bu
2.0

2.0
to

to
re

re
he

he
k

k
lic

lic
C

C
w om w om
w

w
w. w.
A B B Y Y.c A B B Y Y.c

Sources
• http://www.lamisil.com/
• http://www.journals.uchicago.edu/CID/journal/issues/v3
0n4/990666/990666.text.html?erFrom=-
0n4/990666/990666.text.html?erFrom=-
Statement of Antibiotic
4860378516935905751Guest
• http://www.mycology.adelaide.edu.au/downloads/antifu
Prophylaxis
ngals.pdf#search=%22antifungal%20drugs%22
• http://inventors.about.com/library/inventors/blnystatin.h
tm

Dental procedures for which

Cardiac conditions associated with the highest risk endocarditis prophylaxis is
of adverse outcome from endocarditis for which
prophylaxis with dental procedures is reasonable.
reasonable for patients
ADA 2008
• All dental procedures that involve
• Prosthetic cardiac valve or prosthetic material used for cardiac valve repair – manipulation of gingival tissue or the periapical region
• Previous infective endocarditis of teeth or
• Congenital heart disease (CHD)*
– Unrepaired cyanotic CHD, including palliative shunts and conduits – perforation of the oral mucosa.
– Completely repaired congenital heart defect with prosthetic material or device,
whether placed by surgery or by catheter intervention, during the first six
months after the procedure† • * The following procedures and events do not need
– Repaired CHD with residual defects at the site or adjacent to the site of a prophylaxis: routine
prosthetic patch or prosthetic device (which inhibit endothelialization)
• Cardiac transplantation recipients who develop cardiac valvulopathy – anesthetic injections through noninfected tissue, taking dental
radiographs,
• * Except for the conditions listed above, antibiotic prophylaxis is no longer – placement of removable prosthodontic or orthodontic appliances,
recommended for any other form of CHD. – adjustment of orthodontic appliances, placement of orthodontic
• † Prophylaxis is reasonable because endothelialization of prosthetic material brackets, shedding of primary teeth, and bleeding from trauma
occurs within six months after the procedure to the lips or oral mucosa.

Summary of major changes in updated

document.

• bacteremia resulting from daily activities is much more likely to

cause infective endocarditis (IE) than bacteremia associated with a
dental procedure.

• only an extremely small number of cases of IE might be prevented

by antibiotic prophylaxis even if prophylaxis is 100 percent effective.

• antibiotic prophylaxis is not recommended based solely on an

increased lifetime risk of acquisition of IE.

• limit recommendations for IE prophylaxis only to those conditions

listed in S 46

9
 F T ra n sf o F T ra n sf o
PD rm PD rm
Y Y
Y

Y
er

er
4/14/2011
ABB

ABB
y

y
bu

bu
2.0

2.0
to

to
re

re
he

he
k

k
lic

lic
C

C
w om w om
w

w
w. w.
A B B Y Y.c A B B Y Y.c

AAOS Statement
Antibiotic prophylaxis is NOT
recommended for dental patients
with plates, pins, or screws, nor is
it routinely recommended for
MOST dental patients with TOTAL
JOINT REPLACEMENTS.
Legal Considerations
• The dentist may not be aware of the
patient’s medical condition.
• Physician may not be aware of the advisory
statements or of the dental procedure to be
performed.
• Vicarious Liability: “The devil made me do
it”
• “I forgot to take my antibiotic.”
• Documentation.

Principles of Antibiotic Therapy

In Summary…. • Therapeutic effectiveness

– Clinical indications
• Pharmcodynamics, pharmacokinetics
– Age and extent of infection

Dental Infection

Patient factors
Acute—Rapid growth

• Age, allergies, compliance, pregnancy risk

Chronic > 3 days
< 3 days

• Patient function Think Anaerobes

– Renal, hepatic, immunosuppresion, route
Pen VK 500mg q6h or
Add Metronidazole 250-
Amox 500mg q8h or
500mg
applicability
Cephalosporin
To PCN, Amox, or Ceph

• Cost
– Brand name, length of course, alternatives? Allergic to PCN Clindamycin 300mg q8h

Clindamycin 300mg q8h or

Cephalosporin (check
allergic Rxn) or
Azith or Clarithromycin

10
 F T ra n sf o F T ra n sf o
PD rm PD rm
Y Y
Y

Y
er

er
4/14/2011
ABB

ABB
y

y
bu

bu
2.0

2.0
to

to
re

re
he

he
k

k
lic

lic
C

C
w om w om
w

w
w. w.
A B B Y Y.c A B B Y Y.c

DRUGS COMMONLY DRUGS COMMONLY

PRESCRIBED IN DENTISTRY PRESCRIBED IN DENTISTRY
• Narcotics • Psychoactive drugs
– Produce insensibility – Assists in “pain free” dentistry
– Suppress the cns
– Two main categories
– Sedative
• Nonopiod – Can be hypnotic
– Includes the nonsteroidal antiinflammatory drugs – Suppress REM (rapid eye movement)
– Acetaminophen, ibuprofen, aspirin – Includes the drug valium
– Indicted for mild to moderate pain – May not necessarily be prescribed by the dentist.
• Opioid
– For moderate to moderately severe pain
• Amphetamines
– Usually prescribed as a combination drug – CNS stimulant
– Includes codeine, demerol, perocan and darvon – Often seen as a appetite suppress
– Includes dexedrine, caffeine, and metabolife

DRUGS COMMONLY DRUGS COMMONLY

PRESCRIBED IN DENTISTRY PRESCRIBED IN DENTISTRY

• Vasoconstricators – Atropine sulfate

– Epinephrine
• Contracts the arterioles
• Produces cardiac stimulation, bronchial relaxation
and inhibition of interstinal smooth muscle action
• Used in anesthesia and severe allergies responses
• Also found in retraction cord
– Antihistamines
• Used to treat minor allergic reactions
• Causes the patient to be drowsy or dizzy
• Controls the secretion of saliva and mucous
• Administered orally two hours prior to treatment
– Hemostatic
• Arrest the flow of blood
• Not effective against profuse bleeding
– Oxygen
• For resuscitative procedures
• All staff should be familiar with equipment.

DRUGS COMMONLY DRUGS COMMONLY

PRESCRIBED IN DENTISTRY PRESCRIBED IN DENTISTRY

• Hemostatica • Corticosteroids
– Arrest the flow of blood – For inflammatory and immune mediated
conditions
– Not effective against profuse bleeding
– Hydrocortisone is an endogenous agent –
– Three main types used in dentistry cause blood levels to spike during stress
• Gelfoam used at extraction sites
• Surgicel used at extraction sites
• 2x2’s, cotton rolls, retraction cord

11
 F T ra n sf o F T ra n sf o
PD rm PD rm
Y Y
Y

Y
er

er
4/14/2011
ABB

ABB
y

y
bu

bu
2.0

2.0
to

to
re

re
he

he
k

k
lic

lic
C

C
w om w om
w

w
w. w.
A B B Y Y.c A B B Y Y.c

Corticosteroids Corticosteroids
• Systemic
• Topical • Common clinical use:
– Triamcinolone acetonide 0.1%
– Kenalog in Orabase
– RAU
– Hydrocortisone 1% • Aim of treatment is to intercept the development of the
– Betamethasone 0.5 mg ulcerative of the lesion by the broad based
– Beclomethasone spray
immunosuppressive activity
• Intra
Intra--lesional injection • Pt are to apply the agent immediately after the first
– Severe disease and chronic lesions that plateau and not progress to a healing prodromal awareness of a lesion present
phase
– Lip : atrophy & sclerosis – LP
• GC may improve some components of the local tissue lesion
• Common clinical use:
– RAU • The underlying and persistent immune mechanisms remain
– LP active

Corticosteroids Corticosteroids
- adverse reaction
• GC do not have an effect on the primary
disease mechanism • Secondary condidosis
• Nausea
• It minimize both disease activity and • Refractory response
clinical morbidity – Poor compliance
– Inappropriate instruction
• May also plat a role in the development of – Inappropriate application
– Incorrect diagnosis
preventive strategies – Failure to remocve local cause
– Insufficient potency
• Mucosal atrophy
• Delayed healing
• Systemic absorption

Corticosteroids
Steroid
- guidelines for topical GC
hydrocortisone sodium topical corticosteroid minor aphthae QDS - during ulcer attack

• No medical contraindication succinate 2.5 mg tablets multi-inflammaory

(Corlan) effects

• Confident of clinical diagnosis Triamcinolone 0.1 % on as above minor/major aphthae apply QDS to dried arae

• Provide detailed instruction Orabase (Adcortyl) esp in ant portion

of mouth
around ulcer moistened
finger

• Do not apply on lips and skin Betamethasone sodium as above minor/major aphthae TDS, dissolve in 10 mls of

• Monitor the amount used

phosphate o.5 mg tab unresponsive to Corlan
& Adcortyl
water, use as mouthwash,
hold in mouth for 3 min then

• Monitor the response

discard

• Monitor the adverse reaction

Beclomethasone
dipropionate spray
as above aphthae affecting labial 2 puffs (100 ug) spray onto
mucosa mucosa

• Taper withdrawal to ensure recurrence is

(Beconase)

minimize tetracycline 250 mg

capsules
anti microbial &
undefined anti
herpetiform Aphthae dissolve contents of capsule
in 10 mls of water, use as

• Encourage short term, intermittent use inflammatory mouthwash. hold in mouth

3 min then discard

12
 F T ra n sf o F T ra n sf o
PD rm PD rm
Y Y
Y

Y
er

er
4/14/2011
ABB

ABB
y

y
bu

bu
2.0

2.0
to

to
re

re
he

he
k

k
lic

lic
C

C
w om w om
w

w
w. w.
A B B Y Y.c A B B Y Y.c

Recording PRESCRIPTION WRITING

– A record must be kept of each
prescription written or administered to a
patient
– A duplicate or carbon copy may be used
and placed in the patient’s chart
– The drug dispense is written in the
patient’s chart.
• Under no circumstances may a dental
assistant prescribe medication!!
• Dispensing of medicaiton may only be
completed with explicit instructions from
the dentist.

13