R. John Brewer NREMT-P Dental Education Inc.

 The administration of drugs is common in the practice of dentistry and oral surgery.  The majority of the drugs used in dentistry can be divided into four categories. 1. Local anesthetics 2. Analgesics 3. Antibiotics 4. CNS Depressants

 Important part of the dental treatment plan when potentially painful procedures are considered.

 Prescribed for relief of preexisting pain or alleviation of potential post-operative pain.

 Used in the management of infections

 Prescribed for all phases of the dental treatment for the prevention and management of dentistry related fears.

 Whenever a drug is administered, a rational purpose should exist for its use.  Indiscriminate administration of drugs is one of the major reasons the number of incidents of serious or life threatening emergencies in the medical and dental office have increased.

 It is estimated well over 100,000 patients have died in hospitals due to adverse drug reactions.  It is estimated that over 2 million patients have suffered serious but non fatal adverse drug reactions.

 Toxicology is the study of the harmful effects of chemicals on biological systems. These effects range from minor to serious, or even cause death.  Whenever a drug is administered, two types of reactions may be noted. - Desirable drug reaction - undesirable drug reaction

 General principles of toxicology - No drug ever exerts a single action. - No useful drug is entirely devoid of toxicity. - The potential toxicity of the drug rests in the hand of the user.

 Our goal is to give the correct drug in the correct dose, via the correct route to the correct patient at the correct time for the correct reason.  It is very important you know about the drugs that you have in the office or prescribe to the patient.

 Most Adverse drug reactions do not pose a threat to the patients life.  There are three responses to drugs that are life threatening: - Overdose reaction - Allergic reaction - Idiosyncrasy reaction

 A condition that results from exposure to toxic amounts of a substance that does not cause adverse effects when given in smaller amounts.

 Defined as a hypersensitive response to an allergen to which the individual has been previously exposed, and now has developed antibodies.  Allergic reaction is possible with any drug or substance.

 The drugs and substances most likely to cause allergic reactions. - Aspirin - Penicillin - Bisulfites - Latex

 An individuals unique hypersensitivity to a particular drug, food, or other substance.  Management is to position the patient, ABC’S are vital.

 The major cause of drug related emergency situations in the dental office is the “administration” of local anesthetics.  Although true Adverse reactions occur,most reactions are related to the injection(seeing the needle)

 Syncope and hyperventilation are the most common “drug related” emergencies.  These episodes usually result from emotional stress receiving the local, not from the drug itself.

 There are four main categories of drugs used in patient management.  1. local anesthetics  2. Antibiotics  3. Analgesics  4. antianxiety drugs

 Locals is the most widely used drugs, are the safest, and most effective drugs for the prevention, and management of pain.  It is important to stress again that most adverse drug reactions to locals are a result of the administration, not the drug.

 The next most common adverse drug reaction is the toxic reaction. This is produced by a relative overdose secondary to accidental intravascular injection.  True documented allergic reactions to locals is extremely rare.

 Prescribed to treat established active infections  Should only be used when indicated due to resistant bacteria strains and allergies.

 Pain relieving drugs make up a significant portion of scripts written by dentists.

 Two categories of analgesics mild- non opioid strong opioid

 Mild- asa, ibuprofen, Tylenol Strong- Opioid- codeine, demerol, diludid, vicodin oxycontin

 Adverse drug reactions to the mild analgesics are GI upset, nausea, constipation, itching  Adverse drug reactions to the opioids are nausea, vomiting, and orthostatic hypotension, respiratory depression, respiratory arrest.

 Aspirin, Tylenol and Codeine remain the most commonly prescribed drugs.

 The use of these drugs for all phases of dental care has increased significantly over the years.  The most common drugs prescribed is the benzodiazepines.

 An overdose of a local is related to the blood level of the local in the myocardium and Central nervous system.  There are several factors which influence the rate at which blood levels increase or for which blood levels remain elevated. These factors could be drug or patient related.

 Normal distribution curve. This is where the majority of patients responds appropriate with “normal dose”, However some are less responsive, and some become more responsive to the local.

 Age Due to absorption, metabolism, and excretion drug doses should be decreased for patients under 6 years and over 65 years. - Weight > Lean body weight more of the drug the patient can tolerate. ***A lack of consideration of body weight is one of the major causes of overdose reactions.

 Pathological process Presence of Pre-existing disease may alter bodies ability to transform a drug into a biologically inactive substance.  Patients with CHF demonstrate blood levels of locals 2x those found in healthy patients receiving the same dose.

 Patients with chronic lung disease are at increased risk for local overdose. CO2 retention results in the decrease of the seizure threshold for local anesthesia. If a patient has a PCO2 of their seizure threshold is lowered by approx 53%.

 Genetics It is been reported that there are certain individuals that possess genetic deficiencies that alter their response to certain drugs.

 Attitude It has been shown that the seizure threshold for locals is lowered in patients who are overly stressed.

 Vasoactivity Locals that are more lipid soluble and more highly protein bound are retained longer, therefore having a slower absorption rate. This increases the margin of safety. The greater the degree of vasodilatation, the more rapid the local is absorbed.

 Dosage :  The larger the dose the higher the peak blood level.

 Route of Administration: Inadvertent intravascular is the factor that causes most overdoses.

 Rate of Injection The rate of injection is vital in the cause or prevention, of overdose reactions to all drugs.

 Local Anesthetic overdose reactions can result from the combination of inadvertent intravascular injection, combined with too rapid a rate of ingestion.  Both 100% preventable

 The more vascular the area, the faster the absorption rate will be.

 The addition of a vasoconstrictor to a local results in a decrease rate of systemic absorption of the drug.

 Low to moderate overdose - Confusion - Talkativeness - Apprehension - Excitedness - Slurred speech - Generalized stutter - Muscular twitching, tremor to face,and extremities

 Nystagmus  Elevated blood pressure  Elevated heart rate  Elevated respiratory rate

 headache  Feeling lightheaded  dizziness  Blurred vision  Ringing in ears  Numbness of tongue  Flushed or chilled feeling  Drowsiness  Disorientation and loss of consciousness

 Management is based on its severity.  -again most cases are mild in nature requiring little or no treatment. Most local overdoses again are self limiting.  Rarely should you go beyond just administering a little 02.  Over treatment has the potential to become a problem.

 It is imperative when administering a local, that the patient remain under continual observation, during and after administration of the local.  Again mild local reactions, will begin in 5-10 minutes following injection.

 Terminate procedure  Position of comfort  ABC’s  02 administration  Vital signs  Iv access  Administration of anti-convulsant.  EMS

 If signs symptoms appear immediately (seconds to 1 minute)intravascular injection is the most likely cause.  Clinical findings are going to be much more severe and rapid.  Patient may immediately become unconscious, and have seizures.

 Position patient supine - remove syringe  911  ABC’s  02 administration  Protect patient  Vital signs  IV therapy/ anticonvulsant  Manage the postictal patient

Anxiety after injection Tremors of limbs Diaphoresis Headache Tachycardia/ Bradycardia Elevated blood pressure

 Terminate procedure  Position – semi sitting  ABC’s  Reassurance of the patient  Vital signs every 5 minutes  911  If hypertensive administer vasodilator(NTG)  esmolol  Transfer to hospital

 Whenever CNS-depressant drugs are administered, the possibility exists that an exaggerated degree of CNS depression may develop.  There have been several deaths both Adult and Pediatric due to this.

 The clinical efficacy of a drug is dependent on its absorption into the cardiovascular system and its blood levels in different target organs.(Brain)  Only the inhalation and IV routes of drug administration permit titration of the drug to a precise clinical effect.  Drug absorption via oral or IM is erratic.

 The use of a CNS depressant to obtain deep sedation via a route of administration in which titration is not possible is an invitation to overdose and cannot be recommended.

 Recent administration  Decreased level of consciousness  Unconscious  Respiratory depression  Loss of motor coordination  Slurred speech

 Terminate dental procedure  Place Supine  ABC’s  911  Oxygen administration  Vitals  IV therapy  Reversal agents

 Over sedation and respiratory depression are the primary clinical findings. However they may have : - Altered level of consciousness - Constricted pupils

 RECOGNIZE THE PROBLEM!!!!!  Discontinue treatment  Position  ABC’s  Oxygen  Vitals  IV therapy  Reversal agent

 A majority of the overdoses involve the administration of more than one drug.  Whenever more than one CNS depressant drug is administered, the doses of both drugs must be reduced to prevent exaggerated, undesirable effects.  A reminder that locals are CNS depressants themselves.

 When administering locals in conjunction with CNS depressants, the dose of the local anesthetic should be minimized.  Ensuring a cooperative patient who maintains protective reflexes is the primary goal of sedation.

 Be prepared for emergencies  Individualize drug dosages  Recognize and expect adverse drug effects  Common Factors to those offices that had deaths:  -Improper preoperative evaluation  - lack of knowledge of drug pharmacology  - lack of adequate monitoring.

 The monitoring process should include  -(CNS) direct verbal contact with patient -Respiratory system (Capn0graphy) Pulse OX Cardiovascular system continuous monitoring of vital signs. EKG

 Case #1  Death of a 28 lb. pediatric patient. Patient was given 7.5cc of local.

 Case #2 Robert Pauley 73 y/o gentleman undergoing IV sedation, at some point stops breathing, cardiac arrest. No vitals No Pulse ox No Reversal drugs given Wrong ACLS drugs given Suite filed/ Plaintiff’s family $1,135,000

 Dec  Georgetta Watson 46 y/o female  Root Canal  No history was taken prior to doing procedure  Patient monitored with pulse oximeter

 Pulse ox decreasing  Irregular breathing pattern noted.  Eventually EMS contacted  EMS arrives finds patient in cardiac arrest. Transported to hospital pronounced DEAD.

 Reports indicate a combination of 2 sedation drugs were given in excessive amounts.  No patient history is documented  Patient was not placed on a monitor no documentation of vital signs being recorded  No CPR being performed  Staff did not have BLS training.  NO record of staff training  MD’s license suspended 8/08

 Aug. 13, million dollar awarded to family in wrongful death lawsuit.  This patient went into cardiac arrest 40 minutes after given a combination of 2 sedation drugs.

The patient received the following: - 7mg versed iv push - 75mg Demerol iv push -.7mg atropine - 6mg decadron 1 carpule 2% lidocaine 1: 100,000 3 carpules 3% mepivacaine

 Oct. 15, 2007 Henry Dillow age 25 has 4 wisdom teeth removed. Dead x3 days after surgery from necrotizing fasciitis.

 John Coleman was a 47 y/o male patient Needed multiple extractions. Given 2mg halcion. Patient did not respond well to drug. Staff restrained patient do DMD could finish procedure.

 Following procedure patient given flumazenil. Apparently at that point patient went into cardiac arrest.  EMS transported patient to hospital, anoxic brain death, taken off ventilator the next day and pronounced dead.

 Wife files suit against office stating the following:  Office not prepared to handle emergency  Patient was over sedated  Delay in 911 call  In addition “DOCS” also being sued since they did the training.

This patient had a history of obesity, diabetic, and colon cancer.

 A patient in Wheeling, was administered 17 tablets of 0.25 mg halcion, for total dose of 4.25mg. A reminder an overdose can occur at 2 mg.