MDA : Ch-30 MDA : Ch-30 DENT-215 SEEMA JAIN Copyright C 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Elsevier Inc. Principles of Pharmacology.

MDA : Ch-30MDA : Ch-30

DENT-215

SEEMA JAIN

Copyright C 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Elsevier Inc.

Principles of Pharmacology

Introduction

What is Pharmacology? Pharmacology is derived from the prefix

Pharmaco-, meaning “drug or “medicine” and the suffix –logy, meaning the “study”

What is a drug? It is any chemical substance that affects

biologic systems, and possesses the following characteristics; selectivity of action, reversibility of action, and certain degree of potency, and the ability to interact with a biological system.

Why dental professionals need pharmacology?

1) To obtain a health history 2) Administering drugs in the office 3) Handling emergency situations 4) Planning appointments (Asthmatic

pts, diabetic pts) 5) Choosing self-medications (OTC) 6) Discussing drugs

Overview of Drugs Drug Derivatives

Organic: Drugs derived from living organisms such as plants or animals

Inorganic: Drugs synthesized in the laboratory

Identifying Drugs Chemical name: Drug’s chemical formula Generic name: Name that any business

firm may use e.g. acetaminophen Brand or trade name: Registered

trademark e.g. Tylenol


Naming of drugs…

Generic Name (One): Relating to or descriptive of an entire group or class.

Trade Name (Many): of the drug is also known as the brand name.

This trade name, is protected by the Federal Patent Law for 17 years.

Generic Name Trade Name

acetaminophen Tylenol

lidocaine Xylocaine,

Octocaine

diazepam Valium

acyclovir Zovirax

nystatin Mycostatin


Dispensing of Drugs

Drugs are classified in two categories: Patent Medicines (over-the-counter)

Drugs that can be obtained without a prescription

Prescription Drugs Also referred to as “Ethical Drugs” Supplied by a pharmacist who has received a

prescription

Federal regulatory agencies…

Food and drug administration (FDA) It is charged with protecting public health by ensuring

that drugs are safe and pure, Agency that has to approve the marketing of drugs in US. Determines what drugs can be sold OTC as opposed to

by prescription. Drugs will remain in a clinical trial until they are

approved by the FDA Federal trade commission (FTC)

Regulates the trade practices of drug companies and prohibits false advertising of foods, OTC and cosmetics.

Chemical substances harmless, and products safe, effective, and honestly labeled for OTC.


Federal regulatory agencies…

Drug enforcement administration (DEA) To enforce the controlled substances laws and

regulations of the United States and to bring to justice system, those organizations, and principal members of organizations, involved in the production and distribution of illegal drugs (narcotic, opioids etc)

Responsibility of recommending and supporting enforcement programs aimed at reducing the availability of controlled substances and precursor chemicals in the domestic and international markets.

Controlled Substance Act

Drug Enforcement Agency (DEA) Scheduled Drugs:

Schedule I drugs have no current accepted medical usefulness and have a high potential for abuse. E.g. LSD (lysergic acid diethylamide), Marijuana

Schedule II drugs have a high potential for abuse but have accepted medical usefulness. E.g. cocaine, morphine

Schedule III drugs have less abuse potential and do have accepted medical usefulness. E.g. Tylenol w/ codeine

Schedule IV drugs have low abuse potential and have accepted medical use. E.g. Valium, Librium

Schedule V drugs are not required to be prescribed. E.g. cough medicines

What is it that makes marijuana more frightening to the federal government than cocaine or morphine? The Drug Enforcement Administration has steadfastly, over decades, listed marijuana as a Schedule I drug, meaning that it has no medical value and that the potential for abuse is high.

Cocaine and morphine, far more dangerous and habit-forming, are listed as Schedule II because they have some medical value.

In June 2010, the Oregon Board of Pharmacy reclassified marijuana from a Schedule I drug to a Schedule II drug.


Drug Reference Materials

Physicians’ Desk Reference Also referred to as the “PDR” An updated source of information supplied by

drug companies about their products Available as a bound text or CD-ROM

Package Inserts Information sheet describing

the drug for the patient Side effects Adverse or long-term effects Precautions Contraindications Dosage and route

Drug Dosage Dosage is the amount of a drug that a

patient takes. Specific factors in determining the

dosage are: Age Weight Time of day the drug is taken Drug form Patient tolerance to drug Other drugs the patient is taking

Adverse Drug Effects

Side Effects

Body's reaction to a drug

Allergic Reactions

The body has an increased sensitivity to a substance

Anaphylaxis

Sudden onset of an allergic reaction to a drug

Drug Tolerance

Loss of effectiveness of a drug

Drug Addiction

Physical dependence on a certain drug


Common Side Effects of Medications

Hyperexcitability Insomnia Dizziness Drowsiness CNS effects GI disturbances

(nausea,vomiting,diarrhea) Hypertension Hypotension and fainting Weight changes Appetite changes

Edema Sexual dysfunction Sweating Oppurtunistic infections

(yeast /fungal) Photosentivity Loss of hair Blurred vision Cardiacarrhythmia Skin changes Respiratory difficulties

What does it mean for a drug to have adverse effects?

What is the most common drug that causes an anaphylaxic reaction?

(Penicillin.)

Routes of Drug Administration

Fig. 30-4 Routes of drug administration (From Young A, Kennedy D: Kinn’s the medical assistant: an applied learning approach, ed 9, Philadelphia, 2003, Saunders; Chester GA: Modern medical assisting, Philadelphia, 1998, Saunders; and Daniel SJ, Harfst: Mosby’s dental hygiene: concepts, cases, and competencies, 2004 Update, St. Louis, Mosby 2004)

Few ways that drugs are administered? Oral route in the form of pills, tablets,

capsules, or liquids. Topical route by applying on the surface

of the mucosa or skin. Transdermal route through a patch that

continuously releases a controlled quantity of a medication through the skin.

Stages of Drug Action in the Body

Drug Absorption

Absorption is the process by which a drug enters the bloodstream without being chemically altered or

The movement of a drug from its site of application into the blood or lymphatic system

Drug Absorption

The rate at which a drug reaches it site of action depends on: Absorption - involves the passage of

the drug from its site of administration into the blood. Kidney: Nearly all drugs filtered at the glomerulus

Distribution - involves the delivery of the drug to the tissues

Routes of Drug Administration

The route of administration (ROA) that is chosen may have a profound effect upon the speed and efficiency with which the drug acts

ImportantInfo

The possible routes of drug entry into the body may be divided into two classes:

EnteralParenteral

Enteral Routes

Enteral - drug placed directly in the GI tract:sublingual - placed under the

tongueoral - swallowing (p.o., per os)rectum - Absorption through the

rectum

Parenteral Routes

Intravascular (IV, IA)- placing a drug directly into the blood stream

Intramuscular (IM) - drug injected into skeletal muscle

Subcutaneous - Absorption of drugs from the subcutaneous tissues

Inhalation - Absorption through the lungs

The ROA is determined by the physical characteristics of the drug, the speed which the drug is absorbed and/ or released, as well as the need to bypass hepatic metabolism and achieve high conc. at particular sites

ImportantInfo

No single method of drug administration is ideal for all drugs in all circumstances

Very Important

Info!

Prescription Writing

Definitions of Prescription

A written direction for the preparation and administration of a remedy

A summary of the diagnosis, prognosis, and treatment plan for a patient’s illness

A legal document

Health Doctor's scrawl blamed for patient death http://news.bbc.co.uk/2/hi/health/521157.stm

A US jury has awarded a huge damages settlement following the death of a patient caused by illegible handwriting on a prescription. Texas-based cardiologist Dr Ramachandra Kolluru gave patient Ramon Vasquez what he said was a prescription for the angina drug Isordil. However, because of the doctor's untidy writing, a pharmacist dispensed Plendil - a high blood pressure medication - instead. In fact, the dose of Plendil was double the recommended maximum daily amount. Mr. Vasquez subsequently had a heart attack and died several days later. His family sued both the doctor and the pharmacist for negligence. The jury in the case found both equally liable, awarding a total of $450,000 in damages.

Doctors' sloppy handwriting kills more than 7,000 people annually. It's a shocking statistic, and, according to a July 2006 report from the National Academies of Science's Institute of Medicine (IOM), preventable medication mistakes also injure more than 1.5 million Americans annually. Many such errors result from unclear abbreviations and dosage indications and illegible writing on some of the 3.2 billion prescriptions written in the U.S. every year.

JOKE ABOUT PENMANSHIP

A joke was in circulation about a chemist who started picking up medicines on reading a personal letter of a customer who had brought it to him thinking that the chemists are capable of reading illegible writings.

TILL THE TIME YOU GET PRINTED PRESCRIPTION FROM YOUR PHYSICIAN, A FEW STEPS WORTH TAKING:• Try to read prescription yourself before leaving doctor’s clinic. If the medicine and dose is not clearly readable, ask the doctor to rewrite the prescription.• Ask the doctor to tell you verbally the name of medicine and dosage and compare that with what you can read on the prescription note.• Ask the chemist to read aloud the name of medicine before picking up.• Read the name of the medicine to match with the prescription.It may be time consuming but worth taking trouble.

e-Rxe-prescribing

Prescriptions

Written order by a physician or dentist for the preparation and administration of a medicine by the pharmacist.

Components of Written Prescriptions

All written prescriptions should contain: Patient's full name and address Prescriber's full name, address, telephone

number, and DEA number Date of issuance Signiture of prescriber Drug name, dose, dosage form, amount Directions for use Refill instructions

Sample Prescription

Prescriptions

Written order by a physician or dentist for the preparation and administration of a medicine by the pharmacist.

Prescription Terminology Superscription: patient name, address, date,

Rx Inscription: Name and quantity of the drug Subscription: Directions for mixing the drug Signature: Instructions for the patient on how

to take the drug

Fig. 30-1 Example of a prescription pad. (Courtesy Colwell Systems, Champaign, IL.)

UCLA HOSPITAL & CLINICS 10833 Le Conte Avenue

Los Angeles, California 90024 (310) 825-6301 (PAGE)

Name (print) Age

Address City Date

R

SPANISH LABELNON-CHILD-PROOF CAPS

REFILL ________ TIMES

CLINIC ___________________ SIGNATURE OF PRESCRIBER CAL LIC. NO.

DEA NO.PRESCRIBER'S UCLA I.D. NO. PRESCRIBER MUST PRINT/STAMP NAME

PHARMACIST: IF WRITTEN FOR CONTROLLED SUBSTANCE GET POSITIVE I.D.

Components of a prescription

Superscription Rx = recipe, Latin for “take thou” Denotes paper is a prescription Rx symbol for Jupiter

Patient’s name, age and address Pharmacist needs this information.

Name and address required; age useful check for dosage

Date Required for all prescriptions

Lotta CelivaAdultYou decide (pharmacist often fills this out for you)

11/5/01

Components (2)

Inscription Contains the name and amount of each

medication Avoid abbreviations and indicate

amounts in metric


11/5/01

Atropine sulfate 0.4 mg

Components (3)

Subscription Directions to the pharmacist, usually

only how much to dispense. The following is an exception from Accepted Dental Remedies (1937)

RDentifrice

Hardsoap, in fine powder 50 gPrecipitated Calcium Carbonate 935 gSoluble Saccharin 2 gOil of Peppermint 4 ccOil of Cinnamon 2 ccMethyl Salicylate 8 ccTo make about1000 g

Thoroughly triturate saccharin, oils and methyl salicylate with one-half of the calcium carbonate and mix the soap with the remainder of the calcium carbonate. Mix the two powders thoroughly and pass through a fine sieve.


11/5/01

Atropine sulfate 0.4 mg Dispense 2 tablets

Components (4)

Signature (Label) Directions to the patient. What the

pharmacist puts on the label. Write in English for better compliance.

Lotta CelivaAdultYou decide (pharmacist usually fills this out for you)

11/5/01


Dispense 2 tablets Label: Take 1 tab 2 hours before

dental appointment.

Common Prescription Abbreviations

a.a. of eacha.c. before mealsa.m. morningb.i.d twice a dayt.i.d. three times a day q.i.d. four times a daycaps. capsulesdisp. dispenseh. hourh.s. at bedtime, hour of sleepNPO nothing by mouthp.c. after mealsPO by mouthp.r.n. as neededq. every, eachq.d. every dayq6h every 6 hourssig. labeltab. Tablett, tsp teaspoonT, tbs tablespoonut.dict. as directed

Some of the common latin prescription abbreviations include:

· ac (ante cibum) means "before meals" · bid (bis in die) means "twice a day" · hs (hora somni) means "at bedtime" · po (per os) means "by mouth" · pc (post cibum) means "after meals" · prn (pro re nata) means "as needed" · q 3 h (quaque 3 hora) means "every 3 hours" · qd (quaque die) means "every day" · qid (quater in die) means "4 times a day" · Sig (signa) means "write" · tid (ter in die) means "3 times a day"


Table 30-1 Common Prescription Abbreviations

Components (5)

Refill order Limited for controlled substances (0 for

schedule II, otherwise up to 6). Rarely required in dentistry

Prescriber’s signature and address Be sure to include DDS after name

Prescriptions for controlled substances will require address and DEA number and may have to be prescribed on a special triplicate blank

Lotta CelivaAdultYou decide (pharmacist usually fills this out for you)

11/5/01


Dispense 2 tablets Label: Take 1 tab 2 hours before

dental appointment.

No Your Name, DDSYour Name, DDS

93555

Modifications for controlled drugs Inscription

May use trade name when much easier to write because of analgesic combinations

Subscription Special technique for dosage number to

avoid prescription alteration DEA number Schedule II drugs cannot be called

in except for an emergency (real emergency)

CONTROLLED SUBSTANCE PRESCRIPTIONS (CLASS = SCHEDULE)

C-I Examples -- Heroin, Marijuana, LSDC-II Examples -- Morphine, Methadone, Meperidine (Demerolâ), Codeine, Oxycodone, Mehthylphenidate (Ritalinâ)C-III Examples -- Chlorphentermine, Paregoric, NalorphineC-IV Examples -- Choral hydrate, Phenteramine (Fastinâ), Diazepam (Valiumâ), Lorazepam (Ativanâ), Phenobarbital, Clonazepam (Klonopinâ)C-V Examples -- Cough syrus with codeine, buprenorphine

SCH-II PRESCRIPTIONS

Prescriber's DEA Number Not refillable Valid six months from issuance date Must be signed by prescriber May be faxed if original prescription is presented prior

to dispensing Pre-printed prescriptions are not valid No phone-in orders except for emergency dispensing

Dispensing for emergency situation:a) Permits a verbal order from physician to pharmacistb) Written prescription must be delivered to pharmacist within 72 hours

SCH-III PRESCRIPTIONS

Refillable up to five times in a six month period

Valid twelve months from issuance date

May be faxed May be given as verbal prescriptions Pre-printed prescriptions are not valid

C-V AND UNSCHEDULED PRESCRIPTIONS

Unlimited refills Valid twelve months from

issuance date May be faxed May be given as verbal

prescriptions Pre-printed prescriptions are

valid

Iva PayneAdultYou decide (pharmacist usually fills this out for you)

11/5/01

Amoxicillin 500mgDispense twenty-one (21) tablets Sig: Take 1 tab t.i.d. until gone


93555

AN1234567

Iva PayneAdultYou decide (pharmacist usually fills this out for you)

11/5/01

Vicodin 5/500mgDispense twenty-four (24) tablets Sig: Take 2 tab every 4-6 hr prn

pain


93555

AN1234567

Let’s recap

What part of the prescription includes the name and quantity of the drug?

What part of the prescription includes the instructions for the patient about how to take the drug?

What part of the prescription includes the directions for mixing the drug?

Can a dental assistant prescribe medication to a patient? What is the role of the dental assistant regarding

prescriptions? What does it mean to dispense “50”? What does “prn” mean for the patient as it relates to pain? What are the guidelines with respect to the telephone

interaction of a dental assistant with a pharmacy? What should a dental assistant do when a pharmacist calls?

Why patients have to take pre-med before dental appointments?

Let’s think

What is infective endocarditis and who is at risk for it?

What bacteria is mainly involved in infective endocarditis?

How can the dental office prevent endocarditis in patients who are at risk?

Antibiotic Prophylaxis

Antibiotic prescribed to an uninfected patient to prevent bacterial colonization. Most common application is for the

prevention of infective endocarditis. Bacteria is abundant in the oral cavity

The antibiotic decreases the bacterial colonization or adherence.

Antibiotic Prophylaxis Recommendations

Table 30-2 Recommended Doses and Regimens for Common Antibiotics

Dental patient situation Agent Regimen

Standard general prophylaxis Amoxicillin Adults: 2.0g Children: 50mg

PO 1hr. Before procedure

Unable to take oral medications Ampicilin Adults: 2.0g IM or IV Children: 50mg IM or IV 30 minutes before

procedure Allergic to penicillin Clindamycin Adults: 500mg

Children: 20mg PO 1hr. Before

procedure

PO: orally; IM: intramuscularly; IV: intravenously

What are the three drugs used for antibiotic prophylaxis?

Why do patients need to take another drug besides amoxicillin if they are allergic to penicillin as an antibiotic premedication?

???????

That’s It !

Copyright © 2005 by Elsevier Inc. All rights reserved.

Anesthesia and Pain Control

Chapter 37


Anxiety and Pain Control

A technique of various psychological, physical, and chemical approaches to

prevent and treat preoperative, operative, and postoperative anxiety

and pain.


Methods of Pain Control Anesthetic Agents

(covered in DENT 112)

Inhalation Sedation Antianxiety Agents Intravenous

Sedation General Anesthesia

Inhalation Sedation Nitrous oxide/oxygen (N²O/O²) is a

combination of gases the patient inhales to help eliminate fear and to help relax the patient.

History Dates back to 1844 Dr. Horace Wells first used on his patients

Effects Nonaddictive Easy onset, minimal side effects, rapid recovery Produces stage I anesthesia Dulls the perception of pain


Advantage of Using N²O/O² Administration is simple and

easily managed Services of anesthetist or

other special personnel not necessary

Excellent safety record Minimal side effects Patient awake Recovery rapid Used with all age of patients


Contraindications of Using N²O/O²

Pregnancy: First trimester Nasal Obstruction: Problems inhaling

through the nose Emphysema: Increased O²

Multiple Sclerosis: Breathing difficulties Emotional Stability: Altered perception

of reality


Inhalation Sedation Equipment

Cylinders: Gases are dispensed from steel cylinders, which are colored green for O² and blue for N²O.

N²O machines: Portable or part of the dental unit. Control valves: Control the flow of each

gas. Flowmeter: Indicates the rate of flow of

the gases. Reservoir bag: The two gases are

combined in this bag and the patient draws on it for breathing.


Inhalation Sedation Equipment-cont’d

Gas hose Carries the gases from the reservoir bag

to the mask or nosepiece. Masks: Supplied in sizes for adults and

children The nosepiece through which the patient

breathes the gases. Scavenger system

Protection from the occupational risks of N²O.

Fig. 37-10 Portable Nitrous Oxide System Unit


Exposure to Nitrous Oxide Used only for patient treatment. Never administered for recreational

purposes. How to reduce N²O hazards to dental

personnel Use a scavenger system. Use a patient mask that fits well. Discourage patients from talking. Vent gas outside the building. Routinely inspect equipment and hoses for leaks. Use an N²O monitoring badge system.


Fig. 37-13 Scavenger system


Patient Preparation for Inhalation Sedation

Review health history. Obtain base-line vital signs. Describe the procedure of

administering the gases. Describe the use of the mask and the

importance of nasal breathing. Describe the sensations that the

patient will experience. Reassure the patient.


Assisting in the Administration of Inhalation Sedation

Start with pure oxygen while establishing the patient’s tidal volume.

Slowly titrate the nitrous oxide until the desired results are achieved.

Patients should refrain from talking or mouth breathing.

The N²O/O² analgesia should end with the administration of 100% O² for 3 to 5 minutes.

Obtain postoperative vital signs and compare them to the preoperative recordings.


Antianxiety Agents Sedatives are the drug of choice by physicians

and dentists for relief of anxiety. Criteria for Use

Patients are very nervous about a procedure. Procedures are long or difficult. Mentally challenged patients. Very young children requiring extensive

treatment.


Commonly Prescribed Sedatives

Secobarbital sodium (Seconal) Chlordiazepoxide HCl (Librium) Diazepam (Valium) Chloral hydrate (Noctec): For

children


Intravenous Sedation

Antianxiety drugs administered intravenously throughout a procedure at a

slower pace, providing a deeper stage I analgesia.


Intravenous Sedation-cont’d Patient Assessment

A health history, physical examination, and signed consent are performed.

Baseline vital signs are taken and recorded. Oximetry and electrocardiogram are

completed and recorded. Weight taken and recorded for dose

determination.


Intravenous Sedation-cont’d Patient Monitoring Physiologic measurements taken

and recorded every 15 minutes. Level of consciousness Respiratory function Oximetry Blood pressure Heart rate Cardiac rhythm


General AnesthesiaA controlled state of unconsciousness

with a loss of protective reflexes, including the ability to maintain an

airway independently and to respond appropriately to physical stimulation or

verbal command.

This controlled state loss of consciousness, produces stage III

general anesthesia.


General Anesthesia-cont’d Pharmacologic Make-up

Combination of gases N²O/O²

Halothane or enflurane mixtures Intravenous agents such as

thiopental sodium and methohexital sodium

Four Stages of Anesthesia Stage I: Analgesia

The stage at which a patient is relaxed and fully conscious.

Able to keep his or her mouth open without assistance and is capable of following directions.

Have a sense of euphoria and a reduction in pain.

Vital signs are normal. The patient can move into

different levels of analgesia.


Four Stages of Anesthesia-cont’d Stage II: Excitement

The stage at which a patient is less aware of his or her immediate surroundings

Starts to become unconscious The patient can become excited and

unmanageable Nausea and vomiting can occur This is an undesirable stage


Four Stages of Anesthesia-cont’d

Stage III: General Anesthesia The stage of anesthesia that begins when

the patient becomes calm after stage II The patient feels no pain or sensation The patient will become unconscious This stage of anesthesia can be met only

under the guidance of an anesthesiologist in a controlled environment such as a hospital


Four Stages of Anesthesia-cont’d

Stage IV: Respiratory Failure or Cardiac Arrest The stage at which the lungs and heart

slow down or stop functioning If this stage is not reversed quickly, the

patient will die


General Anesthesia-cont’d

Patient Preparation Preoperative physical examination. Laboratory tests. Patient or legal guardian must sign a

consent form. Preoperative Instructions

Dentist will review the procedure, as well as the risks.

Must not have anything to drink or eat 8 to 12 hours before receiving general anesthesia.

Record Keeping for Sedation Methods

Always document the following measuresand observations: Review of patient’s medical history. Preoperative and postoperative vital signs. Patient’s tidal volume if using inhalation

sedation. Time anesthesia began and ended. Peak concentration administered. Amount of postoperative time (in minutes) for

patient recovery. Adverse events or patient complaints.

MDA : Ch-30 MDA : Ch-30 DENT-215 SEEMA JAIN Copyright C 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Elsevier Inc. Principles of Pharmacology.

Documents

afternoon slide

tylenol slide

administering drugs

knowledge of certain

naming of drugs generic

drugs chemical formula

seema jain slide

dental health