Review

Chapter 7

Are antibiotics useful in treatment caries?

BECAUSE…DECAY NEEDS TO BE TREATED WITH A FILLING NOT ANTIBIOTICS PRODUCED BY: STREPTOCOCCUS MUTANS NO

For a localized dental infection, when is drainage applied?

IF DRAINAGE CANNOT BE DONE OR IF THE CLIENT IS IMMUNOCOMPROMISED…ANTIBIOTICS ARE GIVEN FIRST

WHAT IS Pseudomembranous colitis?

PSEUDOMEMBRANOUS COLITIS, A CAUSE OF ANTIBIOTIC- ASSOCIATED DIARRHEA (AAD), IS AN INFLAMMATION OF THE COLON INFLAMMATION OF THE COLON WHEN GIVEN CLINDAMYCIN

Remember…

DEFINITIONS

DEFINITIONS

DEFINITIONS antibiotic, antiinfective antibacterial The difference among the terms antibiotic, antiinfective, and antibacterial is that antibiotics are produced by microorganisms, whereas the other agents may be developed in a chemistry laboratory (not from a living organism).

WHAT DOES CULTURING MEAN?

CULTURE AND SENSITIVITY IS THE ONLY WAY TO BE SURE A DRUG WILL KILL OR INHIBIT THE GROWTH OF THE INFECTING MICROORGANISMS. Sensitivity involves exposing the organism to test antibiotics and determining whether the organism is sensitive or resistant MEANS GROWING THE BACTERIA

An antibiotic disk with a zone around it shows sensitivity. After the organism is identified, it is grown on culture medium. Observing whether the organisms are sensitive or resistant to certain test antibiotics assists in determining which antibiotic to use in difficult infections. One to two days are required before the results of the test are available. Although antibiotic therapy can start before this time, it may be changed after the results are available. THEREFORE, Antibiotic therapy CAN be initiated BEFORE the results of the test are available. If clinical response has been adequate, the original antibiotic is often continued despite sensitivity results.

CULTURE AND SENSITIVITY IS THE ONLY WAY TO BE SURE A DRUG WILL KILL OR INHIBIT THE GROWTH OF THE INFECTING MICROORGANISMS. Sensitivity involves exposing the organism to test antibiotics and determining whether the organism is sensitive or resistant MEANS GROWING THE BACTERIA

WHAT IS SUPERINFECTION?

AN OVERGROWTH OF ORGANISMS PRODUCED

WHAT ANTIBIOTIC HAS THE HIGHEST INCIDENCE OF GI COMPLIANTS?

ERYTHROMYCIN

GENERAL ADVERSE REACTIONS & DISADVANTAGES ASSOCIATED WITH ANTIINFECTIVE AGENTS

MUST KNOW..

Within the group ONLY Penicillin G is considered to be the natural penicillin *See note See Table 7-3; Page 83 for FYI review

MUST KNOW..

WHAT IS THE MOST COMMON ANTIBIOTIC FOR DRUG ALLERGIES?

PENICILLIN

PENICILLINS

WHAT IS THE USUAL DOSE OF PEN V?

500 mg 4 times a day

PENICILLINS

WHAT IS CLEOCIN?

CLINDAMYCIN

RATIONAL USE OF ANTIINFECTIVE AGENTS IN DENTISTRY Stage 1 Stage 2 Stage 3

RATIONAL USE OF ANTIINFECTIVE AGENTS IN DENTISTRY

Clindamycin or metronidazole would be the best choice to attack the anaerobes in a stage 2 infection

RATIONAL USE OF ANTIINFECTIVE AGENTS IN DENTISTRY

Chapter 8

WHAT ARE ANTIBIOTICS AND ANTIINFECTIVES NOT AFFECTIVE AGAINST?

Fungal or Viral Infections

IS FUNGUS ACUTE, CHRONIC, OR BOTH?

CAN BE BOTH

ANTIFUNGAL AGENTS: Substances that destroy or suppress the growth or multiplication of fungi Infrequent but when present, difficult to treat Insidious (sneaky and quick) More likely to occur on immunocompromised patients Can become chronic (long-standing)

Can be divided into 2 divisions: FUNGAL INFECTIONS MucocutaneousSystemic skin or mucosa commonly seen in the dental setting treated with topical or systemic antifungal agents also, commonly occur in the vaginal canal whole body more serious in nature

HOW COULD AN ORAL CANDIDIASIS INFECTION BE TREATED IN THE MOUTH?

ORAL CANDIDAL INFECTIONS ARE OFTEN TREATABLE WITH ORAL ANTIFUNGAL LOZENGES AND RINSES AN ANTIFUNGAL..

CANDIDA ALBICAN is part of the normal flora; overgrows if patient is on long term antibiotics or ill fitting denture

treatment and the prevention of oral candidiasis is used for both the treatment and the prevention of oral candidiasis in susceptible cases. poor oral absorption: poor oral absorption: is not absorbed from the mucous membranes or through intact skin; taken orally, it is poorly absorbed from the GI tract.

HOW COULD AN ORAL CANDIDIASIS INFECTION BE TREATED IN THE MOUTH?

HOW LONG SHOULD A NYSTATIN RINSE REMAIN IN THE MOUTH?

2 minutes – for the BEST effect

WHAT IS NICKNAMED ‘AMPHOTERRIBLE’?

Amphotericin Bpoorest safety profile Amphotericin B  poorest safety profile Also known as Fungizone Also known as Fungizone AMPHOTERICIN B

WHY ARE VIRUSES DIFFICULT TO TREAT?

MEANING…THEY WILL NOT DESTROY THE HOST OF A CELL THEY CO-OPERATE WITH THE HOST CELLS

Remember also…

SUMMARY – KEY POINTS Works by inhibiting replication of DNA Food does not affect the drug’s absorption The antiviral action of acyclovir includes herpes simplex viruses types 1 and 2 (HSV-1 and HSV-2), Epstein-Barr and varicella- zoster One of the most common adverse effects associated with oral acyclovir is headache. Anorexia and a funny taste in the mouth have been reported rarely (not common).

Remember also…

BY TAKING ABREVA – HOW MUCH IS HEALING TIME REDUCED?

(NOT MUCH ) ONE HALF DAY

WHAT IS THE CATEGORY OF DRUGS CALLED WHEN TREATING HIV?

ANTI-RETROVIRAL DRUGS

Nucleoside reverse transcriptase inhibitor (NRTI)  zidovudine (AZT) (Retrovir) Nonnucleoside reverse transcriptase inhibitor (NNRTI)  nevirapine (Viramune) – specific for HIV 1 Protease Inhibitors  saquinavir (Invirase) Examples of Drugs Used to Treat HIV SEE NOTE

CHAPTER 9

WHY IS EPI USED IN LOCAL ANESTHETICS?

MEANING..THE LOCAL ANESTHETIC LASTS LONGER TO ENSURE PROPER FREEZING OF THE TOOTH AND TISSUES PROLONG DURATION

WHAT ARE SOME EXAMPLES OF LOCAL ANESTHETICS USED TODAY?

The amide lidocaine (Xylocaine) was released in 1952 mepivacaine (Carbocaine) was released in 1960 More recently, bupivacaine (Marcaine) has been made available for dental use

 potent local anaesthesia  reversible local anaesthesia  should be followed by complete recovery without evidence of structural or functional nerve damage  absence of adverse systemic effects & allergic reactions  rapid onset & good duration  should have moderate lipid solubility which allows an anesthetic agent to diffuse across lipid membranes of all peripheral nerves (motor, sensory, autonomic)  adequate tissue penetration  low cost  long shelf life  long shelf life (stability in solution)  ease of metabolism & excretion

WHAT ARE THE TWO GROUPS OF LOCAL ANESTHETICS?

CROSS-HYPERSENSITIVITY BETWEEN AMIDES AND ESTERS IS UNLIKELY AMIDES AND ESTERS

Absorption & L.A. infection tooth ↓ pH ↑ ionization ↑ [H+] local anaesthetic (L.A.) L.A. In the presence of infection, there may be a reduced clinical effect of L.A. due to the ↓’d pH level. The infection site is more acidic and more ionized and less likely to absorb the L.A drug (weak base). *Weak bases are better absorbed when the pH is greater than the pK a EG: Lidocaine’s pKa =7.9(Weak base drug)

IF INFECTION IS PRESENT, HOW DOES THE LOCAL ANESTHETIC REACT?

IN THE PRESENCE OF AN ACIDIC ENVIRONMENT, SUCH AS INFECTION OR INFLAMMATION, THE AMOUNT OF FREE BASE IS REDUCED IT IS HARDER TO FREEZE –LIKELY INFECTION MUST BE CLEARED BEFORE FREEZING IS DONE.

WHAT DOES ADME STAND FOR?

ABSORPTION DISTRIBUTION METABOLISM EXCRETION VERY IMPORTANT!

HOW MANY CARPS ARE MAX FOR LIDOCAINE?

8.5 CARPS

WHY WOULD A HEMATOMA BE PRODUCED?

POOR INJECTION TECHNIQUE OR EXCESSIVE VOLUME

..WHAT IS BEST? IF A WOMAN IS PREGNANT AND ANESTHETIC MUST BE GIVEN…

LIDOCAINE

AMIDES OR ESTERS? WHAT TYPE HAS A GREAT POTENTIAL FOR ALLERGY?

ESTERS

I.Amides I.Amides (Only class of anaesthetics used parenterally) i.Lidocaine (Xylocaine) ii.Mepivacaine (Carbocaine) iii.prilocaine (Citanest; Citanest Forte) iv.bupivacaine ( bu·piv·a·caine ) I.Esters ( I.Esters (No esters are currently available in a dental cartridge) i.procaine ii.propoxycaine iii.Tetracaine Esters **Esters are not used in dentistry as local anesthetics, but used topically. eg. Benzocaine.

LA AGENTNOTES procaine no longer used lidocaine (Xylocaine) most common used least painful can only use 100,000epi mepivacaine (Carbocaine; Isocaine) shortest duration when no epi is needed. bupivicaine (Marcaine) Painful longest duration 6-8 hours articaine (Septocaine) the most potent prilocaine plain (Citanest) Prilocaine epi (Citanest Forte) similar to lidocaine rapidly metabolized SEE NOTE

WHAT IS THE MOST COMMON LA USED IN DENTISTRY?

LIDOCAINE 2% - (1: EPI)

WHICH ONE HAS THE LONGEST DURATION OF ACTION?

MARCAINE

buprivacaine (Marcaine) longest duration of action.Has the longest duration of action. –major advantage  greatly prolonged duration of action. –indicated in lengthy dental procedures when pulpal anesthesia of greater than 1.5 hours is needed or when postoperative pain is expected. Related to lidocaine & mepivacaine More potent but less toxic than the other amides Available in dental cartridges as a 0.5% solution with 1:200,000 epinephrine

WHAT IS BOTH AN ESTER AND AN AMIDE?

ARTICAINE

IF A CLIENT HAS UNCONTROLLED BLOOD PRESSURE – CAN LA BE GIVEN IN A CONTROLLED DOSE?

NO – IT IS BEST TO DELAY TREATMENT

WHAT IS THE MAXIMAL SAFE DOSE FOR A HEALTHY CLIENT?

THE MAXIMAL SAFE DOSE OF EPINEPHRINE FOR THE HEALTHY PATIENT IS 0.2 MG AND FOR THE CARDIAC PATIENT IS 0.04 MG 0.2 MG OF EPI

WHAT IS ORAQIX?

SOMETHING THE RDH CAN USE TO FREEZE THE GUMS

CHAPTER 10

CAN NITROUS OXIDE BE USED ALONE AS AN ANESTHETIC?

NO!

WHAT ARE THE STAGES/PLANES OF ANESTHESIA?

STAGE I – ANALGESIA STAGE II – DELIRIUM OR EXCITEMENT STAGE III – SURGICAL ANAESTHESIA STAGE IV – RESPIRATORY OR MEDULLARY PARALYSIS STAGES…

VERY IMPORTANT…

Stage I – Induction Period Nitrous oxide, as used in the dental office, maintains the patient in STAGE I Analgesia Amnesia Euphoria consciousness Stage II – Induction PeriodExcitement Delirium combativeness Stage III Where most major surgery is performed Divided into four planes Surgical Anesthesia Unconsciousness Regular respiration Decrease in eye movement loss of respiratory control Stage IVMedullary Depression Respiratory arrest Cardiac depression and arrest No eye movement

VERY IMPORTANT…

WHAT IS NITROUS OXIDE?

ANTIANXIETY AGENT + ANALGESIC AGENT COLORLESS AND ODOURLESS GAS

WHY IS NITROUS OXIDE NOT GOOD TO USE AS A GENERAL ANESTHETIC ALONE?

BECAUSE OF ITS LOW POTENCY (MAC > 100), IT IS UNSATISFACTORY AS A GENERAL ANESTHETIC WHEN USED ALONE IF, HOWEVER, ANESTHESIA IS FIRST INDUCED WITH A RAPIDLY ACTING IV AGENT AND N2O/O2 IS ADMINISTERED IN COMBINATION WITH A VOLATILE ANESTHETIC, EXCELLENT BALANCED ANESTHESIA IS PRODUCED MAC > 100

THEREFORE, Nitrous oxide combined with a halogenated inhalational anesthetic (N 2 O/O 2 ) DECREASES THE MAC N 2 O/O 2 is given throughout most surgical procedures that necessitate the use of general anesthesia because it reduces the concentration of other agents needed to obtain the desired depth of anesthesia.

The average percentage of nitrous oxide required for patient comfort is 35%. DELIVERY:  100% O2 (2-3 minutes) → N2O added in 5- 10% increments → until patient response indicates level of sedation reached → after termination of N2O, 100% O2 (at least 5 minutes)

WHY SHOULD THE CLIENT BE PLACED ON 100% OXYGEN AFTERWARDS?

TO AVOID DIFFUSION HYPOXIA

WHAT COLOR IS THE NITROUS TANK?

**REMEMBER THIS! BLUE

Complications have been the result of misuse or faulty installation of equipment NO 2 tank → blueNO 2 tank → blue O 2 tank → greenO 2 tank → green DON’T GET THESE MIXED UP!! Cylinders are “pin coded” to prevent mixing of cylinders and lines NO 2 concentration should be automatically limited and have a fail-safe system that shuts off automatically if the O 2 runs out

WHEN SHOULD NITROUS NOT BE USED?

USE OF NITROUS OXIDE IS CONTRAINDICATED IN PATIENTS WITH ANY TYPE OF UPPER RESPIRATORY OR PULMONARY OBSTRUCTION IF THEY HAVE TROUBLE BREATHING…

CHAPTER 11

KEEP IN MIND…

Stress or anxiety due to dental treatment can be treated with both pharmacologic and nonpharmacologic methods. The treatment of choice is often dependent upon the patient and his or her stress level. The normal sedative dose (calms normal patient without dental appointment) is not expected to produce calmness in the dental patient, but the hypnotic dose (that which induces sleep in the normal patient) can often produce the desired degree of sedation before dental treatment

KEEP IN MIND…

ORAL SEDATIVES OR IV? WHAT IS THE MOST COMMON WAY TO TREAT ANXIOUS PATIENTS?

ORAL SEDATIVES

However, the dose of a particular antianxiety agent effective for a particular patient is vastly variable and thus, is NOT predictable.

WHAT DOES A LARGER DOSE OF ANT- ANXIETY AGENTS PRODUCE?

(A SMALL DOSE PRODUCES SEDATION) INDUCES SLEEP

Antianxiety Agents Sedatives**Hypnotics ** can be sedative or hypnotic – depending on dose; larger doses provide hypnotic effect

WHAT ARE THE MOST COMMON PRESCRIBED ANTI-ANXIETY DRUGS?

SEE NOTE

WHAT IS THE PREFERRED AGENT USED FOR THE ELDERY?

LORAZEPAM

WHAT IS PTOSIS?

DROOPING OF THE UPPER EYELID

IF DRUGS ‘NEED’ TO BE TAKEN DURING PREGNANCY, WHEN IS THE BETTER TIME?

DURING THE 1 ST TRIMESTER, MALFORMATIONS HAVE BEEN REPORTED 2 ND TRIMESTER

Remember..

 OVERVIEW Abuse & Addiction potential is less than that of the barbiturates Physical dependence and tolerance can develop Combining with other CNS depressants can reduce the safety and can become lethal Overdose poisoning is rare; difficult to achieve when used alone The addition of alcohol can result in coma, respiratory depression, hypotension, or hypothermia

WHAT IS EMESIS?

USED WITH OVERDOSE – SUCH AS ACTIVATED CHARCOAL AND SALINE INDUCED VOMITTING

WHAT CAN BE USED TO REVERSE THE EFFECTS OF BENZODIAZEPINES?

IN THE IV FORM flumazenil (ROMAZICON),

WHAT ARE SOME WAYS TO MANAGE INSOMNIA?

 Insomnia Management The following habits should be followed to minimize insomnia : A.Light snack (warm milk) at bedtime B.Awake at 6 AM even if sleep only began at 5 AM C.Exercise during the day, but NOT within 3 hours of bedtime. D.Remaining in bed no longer than 20 minutes without sleeping E.No smoking within 8 hours of bedtime

WHAT ARE SOME WAYS TO MANAGE INSOMNIA?

This next slide will likely be on the exam.. …

Absorption: barbiturates are well absorbed orally and rectally; used intravenously but not intramuscularly Distribution: IV agents are inactivated by redistribution from site of action in the CNS, to muscles, and adipose tissue Metabolism: short- and intermediate-acting barbiturates are rapidly and almost completely metabolized by the liver Excretion: long-acting barbiturates are largely excreted through the kidneys as a free drug

WHAT ARE LONG ACTING BARBITURATES USED FOR?

USED FOR EPILEPSY

phenobarbital (Luminal) most commonly used for its anticonvulsant effect because of its long-acting effects

USED FOR EPILEPSY