L I S A M A Y O , R D H , B S D HC O N C O R D E C A R E E R C O L L E G E

PHARMACOLOGY BOARD REVIEWDH227

KEY STUDY POINTS

• Know what drugs a patient may be taking• Conditions for which drugs are used• Pharmacological effects• Adverse drug reactions• Usual indications• Contraindications

RX ABBREVIATIONS

• Gt=drop• Ac=before meals• Hs=bedtime• Pc=after meals• Po=by mouth• Tab=tablets• Stat=immediately• Prn=as needed• Ud=as directed• Qd=every day• Bid=2x/day• Tid=3x/day• Qid=4x/day• Sig=label, instructions for use

TERMS

• Log dose-effect curve• Therapeutic range of the drug is plotted where the dose

is increasing sharply• Max response of a drug may exhibit is plotted where the

curve plateaus

Max Response

TERMS

• Potency (Jack Daniels)• Function of the amount of a drug to produce an effect• Potency is greater when the dose is smaller

• Efficacy (Beer & Jack Daniels)• Max intensity of effect or response what can be produced

by drug regardless of dose• Administering more drug will NOT increase the efficacy of

the drug but will often increase the probability of adverse drug rxn

• Efficacy and potency of a drug are unrelated!!

SCHEDULE OF CONTROLLED SUBSTANCES

Schedule Abuse Potential Handling

I Highest No accepted medical use

II High Written Rx w/provider’s signature onlyNo Refills

III Moderate Rx may be phones inNo more than 5 refills in 6mo

IV Less Same as Schedule III

V Least Can be purchased OTC

SCHEDULE OF CONTROLLED SUBSTANCES

• Any Rx for a controlled substance requires a DEA #• A designate of the dentist may write the Rx but

the prescriber must personally sign the Rx in ink• Certain states require the use of triplicate Rx

blanks for Schedule II drugs

ROUTES OF ADMINISTRATION

• ENTERAL: oral & rectal1. Oral (PO)• Slow onset• Safest, least expensive and most convenient• Large absorbing area present in small intestine

which causes slower onset of the drug’s effects and may result n stomach or intestinal irritation including nausea and vomiting

• Drugs derived from PRO sources may be activated by GI acidity or enzymes (ex: insulin)

• Drug blood levels are less predictable• Necessitates greater patient cooperation

ROUTES OF ADMINISTRATION

• ENTERAL: oral & rectal1. Oral (PO)• Mechanism of uptake:• Orally delivered drugs must pass through

hepatic portal circulation FIRST (can inactivate other drugs) = called PHASE 1 REACTIONS or FIRST PASS EFFECT (next slide)• Amt of drug available to produce systemic

effect is reduced by first pass

ROUTES OF ADMINISTRATION

1. Oral: Phase I Reactions• Drugs with high first-pass effect have LARGER oral

to parental dose ratio (ex: morphine), they require a LARGER dose

• Carried out by microsomal or cytochrome P-450 enzymes (also known as mixed function oxidases) in LIVER

• Concentration of these enzymes can be affected by drugs and environmental substances (ex: smoking)

• Alcohol tolerance is a common example of P-450 INDUCTION: metabolize drug more rapidly = need larger drug dose for effect

ROUTES OF ADMINISTRATION

• ENTERAL2.Rectal• suppositories, creams, enemas• Can be used if pt is vomiting (EMESIS) or

unconscious• Poorly and irregularly absorbed rectally• Poor pt compliance

• PARENTERAL1. Intravascular2. Intramuscular3. Subcutaneous4. Intradermal5. Inhalation6. Topical7. Sublingual

ROUTES OF ADMINISTRATION

• PARENTERAL1. Intravascular• Most rapid drug response – almost immediate• Absorption phase bypassed• More predictable response• Route of choice for emergency situation• Disadv: phlebitis (caused by local irritation),

drug irretrievability, allergy, side effects of high plasma drug concentrations

2. Intramuscular (next slide)

ROUTES OF ADMINISTRATION

• PARENTERAL2. Intramuscular• Absorption occurs due to high blood flow in skeletal muscles• Useful to provide sustained effect• Deltoid or gluteal regions most common injection sites•Massage increases absorption

ROUTES OF ADMINISTRATION

• PARENTERAL3. Subcutaneous• Route used to administer PRO products• May produce sterile abscess or hematoma• Ex: insulin and local anesthetics

4. Intradermal• Injected into epidermis• Ex: TB test

5. Inhalation• Provides rapid delivery of drug across large surface

area of respiratory mucosa• Ex: inhalers, nitrous oxide

ROUTES OF ADMINISTRATION

• PARENTERAL6. Topical• Directly to body surface• Contraindicated if surface is ulcerated,

burned, or abraded• Local effect results, may have systemic

uptake7. Sublingual• Rapid, easily administered• Ex: nitroglycerine

ROUTES OF ADMINISTRATION

FACTORS THAT ALTER DRUG EFFECTS

• Pt compliance• Pt weight• Tolerance• Pathologic state (kidneys, liver issues)• Time and Route of Admin• Sex• Age• Genetic variation

PHARMACOKINETICS

1. Absorption2. Distribution3. Drug metabolism4. Elimination5. Factors that alter drug effects

PHARMACOKINETICS

1. Absorption• Transfer of drug from site of administration to blood stream• May be active or passive• Rate and efficacy of absorption depend on route of

administration• Lipid soluble drugs readily move across MOST biological

membranes by diffusion (only drugs to pass blood-brain barrier)

• Absorption occurs at MANY sites in the body• Dependent on several factors: drug solubility, circulation at

deposit site, total surface area available for absorption, drug pH, temperature at site, mechanical factors (massaging site)

PHARMACOKINETICS

2. Distribution• Process by which a drug reversibility leaves the

blood stream and enters the system• After being absorbed, drug is distributed to organ

with the highest blood flow (oral doses go to LIVER, sublingual goes to HEART)

• Dependent on: blood flow, capillary permeability (blood-brain barrier), binding of drugs to PRO (esp plasma albumin)

PHARMACOKINETICS

3. Drug Metabolism• LIVER is major site for drug metabolism• Liver disease or present/past substance abuse can impair metabolism

PHARMACOKINETICS

4. Elimination• Terminates the drugs effects• Drugs most often eliminated by BIOTRANSFORMATION

and/or EXCRETION into urine or bile• Renal excretion most important and most common via

URINE• May be excreted unchanged or as metabolites• Fat soluble drugs are NOT excreted in urine (need to

be metabolized into water soluble by liver)• Other elimination routes: Liver, kidney, lungs, bile, GI,

sweat, milk, exhalation, saliva, gingival crevicular fluid

PHARMACOKINETICS

5. Factors that Alter Drug Effects• Pt compliance• Psychological factors• Tolerance• Pathologic state• Time of admin• Route of admin• Sex• Genetic variation• Drug interactions• Age, weight• Environment

ADVERSE EFFECT - TERMINOLOGY

• Adverse side effect: undesirable response, dose-related, ex: GI upset with aspirin• Toxic effect: excessive dose, ex: chemotherapy• Local effect: ex: necrosis at site of injection

(NBQ)• Idiosyncratic rxn: abnormal drug response that is

usually genetically related• Drug Interactions: effect of one drug is altered by

another, may result in toxicity or lack of efficacy

ADVERSE EFFECT - TERMINOLOGY

• Allergic rxn: an immune response, not dose-related• NBQ: What are the characteristics or sign and

symptoms of an allergic rxn?• Latex allergy may be on boards• Inflammation, itchy skin, watery eye, nose• Bronchoconstriction: severe → anaphylaxis

• Teratogenic effect: drug induced birth defect (NBQ), ex: Thalidomide induction of phocomelia (shortened limbs)

HELPFUL HINTS

• What meds would you use to treat:

Mild allergic rxn?Severe reaction?

HELPFUL HINTS

• Answer: mild= antihistamine (Benadryl)severe=epi

HELPFUL HINTS

• Drugs that DO NOT cause hyperplasia: digoxin, beta blockers, tegretol• Know which drugs will cause gingival

overgrowth/hyperplasia:• Cyclosporin Organ Transplant• Phenytoin (Dilantin)

Anticonvulsant• Ca-channel blockers (Nifedipine)

Antihypertensive• Mouth-breathing• Genetic factors

AUTONOMIC NERVOUS SYSTEM

• Automatic Nervous System• Self-governing, involuntary• Responsible for blood pressure, heart rate, GI

motility, salivation, bronchial/smooth muscle tone• Required neurotransmitters• 2 Divisions:

1)Sympathetic(SANS): Fight or Flight2)Parasympathetic (PANS): Day to day

activities, ensuring energy

PANS

• Rest and digestion system• Functions

1) Dilates blood vessels leading to the GI tract, increase blood flow

2) Constricts bronchiolar diameter3) Causes constriction of pupil and lens4) Stimulates salivary gland secretion5) Accelerates peristalsis6) Activity mediates digestion of food and indirectly, the

absorption of nutrients• NT: Acetylcholine• Pre/post-ganglionic synapse of PANS• Pre-ganglionic synapse SANS

PANS & DRUGS THAT ALTER

• Cholinergic Agents/Muscarinic Drugs• Used to mimic effects of PANS• Used to tx: xerostomia, urinary retention, glaucoma• Ex derived from plant alkaloids• Pilocarpine: stimulates saliva (NBQ)• Nicotine

• Contraindications• Asthma: causes bronchoconstriction• Peptic ulcer: ↑ GI secretions• Cardiac disease: ↓ heart rate• GI/Urinary obstructions: ↑ GI motility

PANS & DRUGS THAT ALTER

• Cholinergic Agents• What do these drugs cause? (MIS)• MyOsis: constrict pupils• Increase bodily secretions: sweat, saliva,

gastric juice• Slowing of heart

• Adverse Rxns: SLUD• Salivation• Lacrimation• Urination• Defecation

PANS & DRUGS THAT ALTER

• Anticholinergic Agents• Dry like the Sahara Desert• What do these drugs do?• Dilation of pupils mydriasis (Dilation eye exams)• Decrease of bodily secretions: decrease fluid flow• Dental implications: decrease salivary flow (NBQ)

• Adverse Effects: NBQ• Blurred vision• Constipation• Dry Mouth

• Uses• Atropine: used to control secretions• Scopolamine: used for motion sickness (NBQ)

SANS

• NT: norepinephrine• Acetylcholine is also the NT for the sympathetic pre-

ganglionic synapses, some post-ganglionic synapses and at some sites in the CNS

• Fight or slight• Functions:

1) Vasoconstriction2) Dilates bronchioles of lung: allow greater alveolar

oxygen exchange3) Increases heart rate4) Dilates pupils

SANS & DRUGS THAT ALTER

Adrenergic agents• Mimic fight or flight response• Uses• Colds• Asthma• Anaphylactic shock• Glaucoma• Vasoconstrictors• Cardiac arrest• CNS stimulation• ADD

SANS & DRUGS THAT ALTER

Adrenergic agents• Examples/Uses (BIG ON BOARDS!)• EPI• Cardiac stimulation (cardiac arrest)• Anaphylaxis• Hemostasis in dentistry• Used in local anes and retention cord• Stops bleeding and prevents systemic

toxicity• Overdose: elevate BP

SANS & DRUGS THAT ALTER

Adrenergic agents• Examples/Uses (BIG ON BOARDS!)• Albuterol• Proventil, Ventolin

• Other• Amphetamine, dextroamphetamine

(Dexedrine)• Pseudoephdrine: decongestant• Methylphenidate (Ritalin): AD/HD

Adrenergic agents• Adverse effects- epi overdose• CNS palpitations, nervousness or tremor, tachycardia

(NBQ)• Cardiac arrhythmias• Cerebral hemorrhage• Pulmonary edema• Anxiety, fear

• Contraindications• Angina• Uncontrolled Hypertension• Uncontrolled Hyperthyroidism

SANS & DRUGS THAT ALTER

ß-Adrenergic Blocking Agents• 2 types of beta receptors: ß-1 & ß-2• ß-1 are in heart (memory hint: 1 heart)• Heart rate, BP• Drugs that block ß-1 receptors lower heart rate and BP

and are useful when the heart itself is deprived of oxygen

• Rx: after heart attacks• ß-2 are in lungs, muscles, arterioles (memory trick 2

lungs)• Non-selective ß-blocker affect ß-1 and ß-2 receptors• Should not be used n pt’s w/asthma or any reactive

airway disease – doing so can block the effects of ß-2 agonists

• Ex: such as albuterol leading to airway and vascular restriction

SANS & DRUGS THAT ALTER

SANS & DRUGS THAT ALTER

ß-Adrenergic Blocking Agents• Useful in treating• Hypertension, angina, cardiac arrhythmias, MI• Hyperthyroidism, migraines, headaches, glaucoma,

performance anxiety

• Drugs to Know (NBQ)• Metoprolol (Lopressor)• Cardio-selective ß-blocker• Used to tx hypertension, prevention of myocardial infarction

and angina

• Atenelol• Cardios-elective ß-blocker• Eliminates bronchoconstriction effect• Used to tx hypertensive asthmatic patients

SANS & DRUGS THAT ALTER

ß-Adrenergic Blocking Agents• Drugs to Know (NBQ)• Timolol: Timoptol, Timoptic• Reduces aqueous humor in the eye• Used topically in tx glaucoma

• Inderol (Propranolol)• Prototype of non-selective ß-blockers• Lowers BP by lowering cardiac output• Adverse rxn: bronchoconstriction, arrhythmias

• Limit epi-containing local anes to 2 carpules in pt’s taking non-selective ß-blockers due to potential increase BP

• Be able to differentiate ß-blocker from diuretics & other meds used in tx High BP

CARDIAC

CARDIAC DISORDERS & DRUGS USED TO TX

• Know suffixes of blockers, Ca-Channel blockers, ACE Inhibitors, etc…• Know sign and symptoms of each condition

1. Angina & Anti-Angina Agents2. CHF3. Heart Disease4. Arrhythmias & Anti-arrhythmics5. Hypertension6. Anticoagulants7. Anti-hyperlipidemics

CARDIAC DISORDERS & DRUGS USED TO TX

• Cardiovascular Contraindications to Dental Tx• Acute myocardial infarction (w/in the preceding

3-6mo)• Unstable (or recent onset) angina• Uncontrolled CHF• Uncontrolled arrhythmias• Significant, uncontrolled hypertension

1. ANGINA & ANTI-ANGINA AGENTS

• Angina• Not enough O2 to the heart cell

• Induced by stress, exercise, emotional state, anxiety• Tx• Nitroglycerine• Amyl nitrate (NBQ)

• Mechanism of Action• Used to dilate blood vessels and stop attack of angina• Reduce the frequency of angina when admin

prophylactically• Drug Interactions• Should not be taken 24HRS of taking sildenafil citrate

(Viagra)

1. ANGINA & ANTI-ANGINA AGENTS

Drugs need to know for Boards:Nitroglycerin• Drug of choice for acute angina• Works as vasodilator (specifically,

nitroglycerin acts as a smooth muscle relaxant)• Generally given sublingually to treat angina

attacks• Dental emergency kit should contain

2. CHF

• Weakened heart muscle, decrease ability to pump O2

• Blood can back up into lungs, liver, organs• Class Symptoms• Edema in legs, shortness of breath

• Caution• With epi = can lead to cardiac arrhythmias

• Digitalis, Glucosides; Digoxin (Lanoxin)• Strengthen heart muscle: increase for of myocardial

contractions• Atrial fib

2. CHF

Digitalis glycosides• Most common type of drug used in tx CHF• Digoxin (Lanoxin) is most commonly used

product• Considerations• In combo w/ sympathomimetic, digoxin can

lead to cardiac arrhythmias; therefore, vasoconstrictors added to local anes should be used w/caution• Tetracycline and erythromycin increase

digoxin levels (in 10% of pt)• Increases gag reflex and salivation

3. HEART DISEASE

• Heart Failure/Myocaridal Infarction• Occurs when O2 starved areas of the heart

begin dying• Can be a result of: Hypertension, Arrthymias,

Heart Valve Disorder, Disorders of the coronary artery, Cardiomyopathy

• Tx• MONA: morphine, oxygen, nitroglycerine,

aspirin

4. ARRHYTHMIAS & ANTI-ARRHYTHMICS

• Normal cardiac rhythm altered by cardiac diseases or injury• Types• Atrial tachycardia's• Ventricular tachycardia's

• Tx• Essentially any of the cardiovascular agents• Lidocaine (sodium channel blockers) (NBQ)• Other blockers• Ca-Channel• Adrenergic• Sodium Channel• Potassium Channel

5. HYPERTENSION

• Silent killer• KNOW BP RANGES FOR ADULTS AND KIDS

120/80 Normal130/90 Pre-HPT140/100 HyperT

108/70 3yrs114/74 6yrs122/78 12yrs

5. HYPERTENSION

• Anti-Hypertensive – Diuretics• Thiazide Diuretics• Hydrochlorothiazide • AE: hypokalemia (decrease potassium)

• Loop Diuretics• Furosemide (Lasix)• AE: hypokalemia

• Potassium Sparing Diuretics• Triamterene (Dyrenium) reduce amt potassium

lost• Drug Interactions• NSAID’s decrease effects

5. HYPERTENSION

Drugs need to know for BoardsThiazide diuretics• HCTZ is the most commonly used thiazide• Frequently assoc w/ xerostomia• Must avoid orthostatic hypotension

Loop diuretics• Flurosemide (Lasix) is the most common• Used in management of hypertension patients

w/CHF

5. HYPERTENSION

• Anti-Hypertensive: Blockers• End in “olol”• Adrenergic agents such as alpha and beta-blockers• Frequently Used• Propranolol (Inderol) Non-Selective• Metopropol (Lopressor) Selective beta-blocker• Atenolol (Tenormin)Selective beta-blocker• Clonodine Older drug but frequently used

• Adverse Effects• Xerostomia• Postural hypotension (fainting because of drug)

5. HYPERTENSION

• Anti-Hypertensive: CCI & ACEI• Calcium channel blockers• Many end with “pine”• Nifedipine (Procardia)• Amylodipine (Norvasc)• Dilate the main coronary arteries by blocking Ca2+

into cell• Adverse Effects• Gingival hyperplasia• Xerostomia

5. HYPERTENSION

Calcium Channel Blockers• Work by producing systemic vasodilation by BLOCKING

vasoconstriction in smooth muscle of blood vessels• One of the few antihypertensive agents whose effect is

NOT reduced by NSAIDs• Common oral manifestations: xerostomia, gingival

enlargement• Common drugs: know these!• Cardizem (Dilitiazem)• Norvasc (Amylodipine)• Verapamil (Isoptin, Calan)• Nifedipine (Procardia, Adalat)

5. HYPERTENSION

Angiotensin Converting Enzyme (ACE) Inhibitor• BP lowered when these drugs block the conversion of

angiotension I to angiotension II (causes vasodilation)• Dysgeusia (altered taste) is common• Adverse rxn: hypotension, allergic rxns, dry cough• NSAIDS decrease effectiveness of ACE Inhibitors• Avoid postural hypotension w/ACE inhibitors• Common drugs: know!• Lisinopril (Prinivil, Zestril)• Captopril (Capoten)• Enalapril (Vasotec)

6. ANTICOAGULANTS

• Interferes with clotting• Warfarin (Coumadin)• Dicumarol (NBQ)• Drug interactions• Aspirin• Vit K

• Uses• Thrombosis (coronary)• Arrhythmia’s• Post-heart attach• Heart valve replacement

7. ANTI-HYPERLIPIDEMICS

• Lipid (CHOL) lowering agents• Works on decreasing LDL = protect against

heart disease• Most popular: STATINS (NBQ)• Atorvastatin (Lipitor)• Lovastatin (Mevacor)

CARDIAC DRUGS

Anticoagulants: therapy attempts to ↓ intravascular clotting• Coumarins: Wafarin (Coumadin) is the most common• Most serious drug interaction of warfarin is w/aspirin• Prevents conversion of inactive Vit K to its active

form• ABX can also potentiate the effects of Warfarin (due

to effect on Vit K)• Consider dose reduction ONLY w/advise of treating

MD; allow several days for a change in effect if dose of warfarin is changed due to latent onset time

• Heparin• One of the most commonly employed anticoagulant

agents in hospitalized pts• Given by injection only

RESPIRATORY AGENTS

RESPIRATORY AGENTS

• Adrenergic agents :1st line of tx (NBQ)• Albuterol (Proventil, Ventolin)

• Corticosteroids• Beclomethasone (NBQ)• Oropharyngeal candida can occur

• Xanthines (how to say: zan-thenes)• Theophylline (Theo Dur)• PO (old therapy)

• Emergency• Status Asthmaticus – EPI!!!

RESPIRATORY AGENTS

• Seasonal Allergy Tx• Histamine released due to inflammatory response• H1 Blocker: antihistamine• Block or inhibit histamine at the receptor site

(NBQ)• EX• Benadryl (Diphenhydramine)• Adverse Rxn: sedation, xerostomia

• Claritin• Cetirizine (Zyrtec)• Fexofenadine (allegra)• Not used to tx anaphylaxis (EPI)

RESPIRATORY AGENTS

1. Asthma2. COPD3. Upper Respiratory Infections

RESPIRATORY AGENTS

1. Asthma• Mild = inhaled ß-agonist as needed

(Albuterol)• Isoproternol rapidly alleviates an acute

attack of asthma when taken by inhalation but is rarely used as a bronchodilator:• Metaproterenol (Alupent) produces dilation of

the bronchioles & improves airway function• Useful as a bronchiodilator in tx asthma and to

reverse bronchospasm

RESPIRATORY AGENTS

1. Asthma• Types inhalers

1. Short-acting bronchodilators: Albuterol, Pirbuterol. Immediate relief of asthma symptoms

2. Corticosteroids: used long-term to prevent asthma attacks. Flovent, Pulmicort, Azmacort, Aerobid

3. Corticosteroids + long-acting bronchiodilator: Advair

4. Long-acting brochodilators: Serevent and Foradil. Relieve asthma symptoms for longer periods of time

RESPIRATORY AGENTS

2. COPD• Anticholinergic’s are 1st line of defense• Controversial information concerning

oxygen admin w/pt’s with COPD• Ipratropium (Atrovent) is the drug of choice

for long-term management of COPD

RESPIRATORY AGENTS

3. Upper Resp Infections• Nasal decongestant are ß-adrenergic agonists

that act to constrict the blood vessels of the nasal mucosa. Should not be used for more then a few days – rebound swelling & congestion• Expectorants – drugs that promote the removal

of exudate or mucus from the resp passages• Antitussives (cough suppressants) may be

opioids or related agents used for the symptomatic relief of a nonproductive cough

RESPIRATORY AGENTS

• Theophylline is an oral med used to tx chronic asthma and the bronchospasm assoc w/emphysema and chronic bronchitis• Erythromycin can increase serum levels of

theophylline and toxicity may result• Aspirin should be avoided in asthmatics (4-19% of

asthmatics have aspirin hypersensitivity)• Albuterol CAN cause insomnia

GI DISORDERS

• Gastrointestinal Reflux: GERD, Peptic Ulcer• H2 Blockers• Blocks histamine and reduce gastric secretions• Ex: Cimetidine (Tagamet), Ranitidine (Zantac) (NBQ)

• Proton-Pump Inhibitors• Most effective – completely blocks production of

hydrochloric acid• Ex: Esomeprazole (Nexium), Lansoprazole (Prevacid)• Ex: Pantoprazole (Protonix), Omeprazole (Prilosec)

• Antacids (TUMS)• Neutralize gastric hydrochloric acid OTC agents used

for the relief of indigestion, etc…• Tip: Aspirin exacerbates

GI DISORDERS

• The pt who lists Tagament on hl hx is likely treated for gastric ulcers• Gastric ulcerations do NOT cause gingival

bleeding

DRUGS FOR DIABETES

• Type I• Insulin dependent• Insulin by subcutaneous injection is most common

tx• Hypoglycemia most common adverse rxn (Insulin

Shock)• Shortness breath is NOT assoc w/hypoglycemia

• Type 2• Non-insulin dependent• Oral hypoglycemics are used to tx• Metaformin (glucophage) & glyburide (DiaBeta,

Micronase) are common examples of oral hypoglycemics

CNS

CNS AGENTS

1. Benzodiazepines2. Barbiturates3. Anticonvulsants4. Antidepressants5. Antipsychotics

1. BENZO’S

• “Pam-Lam” – end of drug names usually end in pam or lam• Tx dental anxiety (NBQ) and TMD• Used to tx short-term: stress, anxiety,

insomnia, alcohol withdrawal• Anxiolytic agent (antianxiety, antipanic)• No antipsychotic, analgesic activity, not affect

ANS• All have sedative properties• Smoking reduced effectiveness

1. BENZO’S

• Reverse status epilepticus and seizure assoc w/local anes overdose• Ex• Alprazolam (Xanax)• Diazepam (Valium)• Lorazepam (Ativan)

• Dental implications (NBQ)• Xerostomia• Drowsiness

2. BARB’S

• Lots of drug/drug interactions• Was Rx as a sedative (Benzo’s have now replaced)• Therapeutic used currently• Sedative/Hypnotic (pre-anesthesia)• Primarily used as anticonvulsant (NBQ)• Ex• Phenobarbitol: long-acting, used to tx epilepsy, no

analgesia effects• Butabarbital (Buticaps) – anticonvulsant• Secobarbital (Seconal)• Pentobarbital (Nembutal)• Thiopental

3. ANTICONVULSANTS

• Hydantoins – Phenytoin – Dilantin• Adverse Effect: gingival hyperplasia (50%)

• Barbiturates: Phenobarbital, Primidone• Used alone or in combo (NBQ)

• Carbamazepine (Tegretol)• Trigeminal neuralgia (NBQ) – sharp pain in face• Bi-polar depression• Recently used in dentistry more to tx trigeminal neuralgia• No gingival hyperplasia!!• Dental implications • Xerostomia• Glossitis• Stomatitis

4. ANTIDEPRESSANTS

• Tricyclic antidepressants• Elavil (Amitryptuline)• Side Effect: severe xerostomia (NBQ)

• Serotonin-Specific Re-Uptake Inhibitors (SSRIs)(NBQ)• Fluoxetine (Prozac)• Sertraline (Zoloft)• Paroxetine (Paxil)

• Tobacco cessation• Buprioprion (Zyban)(Varcenicline) (Wellbutrin)• Chantix

• Bi-Polar Disorder• Mania Tx – Lithium• Drug interaction – w/NSAID’s

5. ANTIPSYCHOTIC AGENTS

• Work by blocking dopamine• 1st generation: Thiazides• Chlorpromazine (Thorazine)• Haloperidol (Haldol)

• 2nd generation: Clozapine (Clozaril)• Adverse Rxns• Extrapyramidal, ie: tardive dyskinesia and

parkinson’s-like symptoms(NBQ)• Schizophrenia• Assoc with increased dopamine (NBQ)

PARKINSON’S DISEASE

• Decrease dopamine• S&S• Bradykinesia, tremors, rigidity, poor balance,

Parkinson’s gait (shuffling)• Difficulty swallowing, excessive salivation,

sweating• Tx• Levodopa (L-DOPA)• Levodopa + carbidopa (Sinemet, Sinemet CR)

GENERAL ANESTHETICS

• Potent CNS depressants• Produce reversible loss of consciousness and

insensitivity to painful stimuli• Nitrous oxide is considered an incomplete anesthetic• IV anes: unusually short acting barbiturates, benzo’s

used for sedation• Benzo (Valium), may be given prior to general sedation• Stages and Planes of Anesthesia

1. Stage I – Analgesia2. Stage II – Delirium or Excitement3. Stage III – Surgical Anesthesia4. Stage IV – Respiratory or Medullary Paralysis

GENERAL ANESTHETICS

• Stages and Planes of Anesthesia1. Stage I – Analgesia: 3 planes• Reduced pain sensation (development of

analgesia)• Pt remains conscious & can still respond to

command• Respiration & reflexes are regular• Nitrous oxide, as used in dental setting, maintains

the patient Stage I plane 1&2• End of this stage = marked loss of consciousness

GENERAL ANESTHETICS

• Stages and Planes of Anesthesia2. Stage II – Delirium or Excitement• Begins w/unconsciousness & is assoc

w/involuntary movement and excitement3. Stage III – Surgical Anesthesia• Most major surgery is performed

4. Stage IV – Respiratory or Medullary Paralysis• Complete cessation of all respiration, if this stage

not immediately reversed = death

NON-OPOID ANALGESICS

• NSAIDs / NSAIAs• Know what they do• Analgesic: relief of pain• Antipyretic: lowers fever, effects hypothalamus (NBQ)• Anti-inflammatory: reduce inflammation• Anti-platelet effect – interferes with clotting• Aspirin (irreversible), ibuprofen (reversible)

• Mechanism of action• Inhibit the synthesis of prostaglandin (lipid compound

derived from fatty acids, are messenger molecules)• Side effects• GI bleeding• Reduced effect of blood pressure meds

PROSTAGLANDINS

Examples of prostaglandin antagonists are:• NSAIDs (inhibit cyclooxygenase)• Corticosteroids (inhibit phospholipase A2 production)• COX-2 selective inhibitors or coxibs• Cyclopentenone prostaglandins may play a role in

inhibiting inflammationClinical uses: Synthetic prostaglandins are used:• To induce childbirth (parturition) or abortion • To prevent and treat peptic ulcers (PGE)• As a vasodilator in severe Raynaud's phenomenon • In pulmonary hypertension• Tx glaucoma• Tx erectile dysfunction • Ingredient in eyelash and eyebrow growth beauty products

NON-OPOID ANALGESICS

• Know classifications and examples• Propionic acid, acetic acid, salicylates• Diclofenac (Voltaren)• Ibuprofen (Advil, Motrin)• Ketoprofen (Orudis), naproxen (Anaprox, Aleve)• Indomethacin (Indocin) and sulindac (Clinoril)• Diflunisal (Dolibid)• Aspirin considered a salicylates (Bayer, Emprin,

St.John, Anacin)• Coupled with opioids: dose-sparing effect –(can give

less)• Best dental analgesic = ibuprofen

NONOPIOID ANALGESICS

Aspirin• Prototype of non-narcotic analgesics• Considered a non-steroidal anti-inflammatory drug (NSAID)• Uses:• Analgesia (reduce pain)• Antipyretic (reduce fever)• Antiinflammatory (reduce inflammation)

• Mechanism of Action: inhibition of prostaglandin synthesis• Fever reduced through action of hypothalamus• Side effects• Interferes w/clotting (contraindicated w/coumadin/warfarin

due to drug interaction• GI irritation (contraindicated w/peptic ulcer)• Hypersensitivity: 15% pt’s , fatal anaphylactic shock rare

NONOPIOID ANALGESICS

Aspirin• Reye’s Syndrome• Kids w/ chicken pox or flu, use of aspirin has been

epidemiologically assoc w/ REYE’S SYNDROME• Acetaminophen used in pediatrics for both its analgesic and

antipyretic action

• Toxicity (termed salicylism)• GI upset/vomiting• Confusion and dizziness• Dim vision• Tinnitus• Coma• Respiratory& metabolic acidosis• Death from respiratory failure

NONOPIOID ANALGESICS

Ibuprofen• NSAID• Mechanism action: inhibition of prostaglandin

synthesis• Action• Analgesic• Antipyretic• Anti-inflammatory

• Side effects• Interferes with clotting (contraindicated w/coumadin/warfarin

due to drug interaction)• GI irritation (contraindicated w/ peptic ulcer disease, irritation

is LESS than w/aspirin)

NONOPIOID ANALGESICS

Ibuprophen• Available in suspension form for pediatric use as an

antipyretic• Know effects & contraindications of NSAIDs for boards• Can decrease pharmacological effects of MANY drugs

including• ACE inhibitors• Aspirin• Beta blockers• Corticosteroids• Cyclosporin• Lithium• Loop diuretics

NONOPIOID ANALGESICS

Acetaminophen - Tylenol• Used as: analgesic and antipyretic only• No anti-inflammatory effects (not an NSAID, no

clotting effects)• No GI upset, preferred drug for pt’s on coumadin

and/or peptic ulcer drugs• Contraindication: liver conditions• Drug of choice for post-op pain w/ compromised

systemic illness and for patients on anticoagulant therapy

• Side effects rare• Overdose: hepatoxicity, liver necrosis, death

OPIOID/NARCOTIC ANALGESIC

• What do they do?• Provide analgesia by blocking pain receptors in brain

w/out loss of consciousness (alter perception of pain)

• Varying degrees based on strength of agent• Used to manage pain when nonopioids fail• Mechanism of action: blocks pain receptors in brain

without loss of consciousness• Be familiar with types of Morphine (protype)• Demerol, Dilaudid, Codeine, Hydrocodon• Codeine can cause emesis, and constipation

• Signs of addiction – pinpoint pupils• Overdose – leads to resp. depression - death

OPIOID/NARCOTIC ANALGESIC

• Methadone• Efficacious for the tx of narcotic withdrawal and

dependence• Taken orally once a day, methadone suppresses

narcotic withdrawal for between 24-36 hours• Only effective in cases of addiction to heroin,

morphine, other opioid drugs (not methamphetamine addiction!)

• Narcan• Opioid antagonist• Used to tx opioid overdose• Should be in dental emergency kit

OPIOID/NARCOTIC ANALGESIC

• Will exhibit pinpoint pupils during use (cocaine)• IV drug abusers need to be pre-medicated with

antibiotics prior to tx due to high vascular bacteremia load• NSAIDs are the best medication for heroin addicts

(no pain therapy should be recommended that alters consciousness)

CODEINE FORMULAS USED IN DENTISTRY

• Commonly used in dentistry with acetaminophen• Tylenol #2-4• Schedule III drug• Antitussive effect – suppresses cough

• Naloxone (Narcan) and naltrexone (Trexan)• Blocks the action of opioids on their

receptors• Used to tx narcotic overdose

DRUGS OF ABUSE

• Marijuana: dilated red bloodshot eyes• LSD: dilated pupils, flashbacks, hallucinogen• Heroin: pinpoint pupils• Cocaine: rapid heart rate, sweating, dilation of pupils,

elevated body temp• NBQ: If you knew someone was on cocaine and

suspected they had taken in the last 24HRS, you would NOT inject local anes agent for the risk of overdose

ENDOCRINE PHARM

• Corticosteroids• Uses: not curative – palliative – short term tx• Allergic rxns• Rheumatic or collagen disorders, lupus• Skin conditions, mild to severe• Acute resp disorders: asthma• Malignancies: leukemia, lymphoma, Hodgkin’s

disease• Dental uses: oral lesions, TMD, oral surgery• Under stressful conditions watch for adrenal crisis• Rule of 2s = 20mg for 2 weeks within 2 years

(needs consult)

ENDOCRINE PHARM

Pancreas: Secretes insulin and glucagon• Insulin: secrete in response to high blood glucose

(hyperglycemia)• Glucagon: secreted in response to low blood glucose

(hypoglycemia)• Hyperglycemia: Glucose over 140, Excess glucose in

blood• Leads to complications – Diabetes Mellitus• Contributing factors that precipitate hyperglycemia• Wt gain, cessation of exercise, pregnancy,

hyperthyroidism, thyroid meds, epi therapy, cortisone therapy, acute infection, fever, stress

• S&S: acetone breath, hot dry skin, rapid breathing• Tx: insulin, oral hypoglycemic agents (sulfonylureas)

ENDOCRINE PHARM

• Pancreas: Hypoglycemia• Bl glucose level low: 70mg/dl and 110mg/dl normal levels• Symptoms: varies person to person• Difficulty concentrating, sweating, nervousness, lack of

coordination, trembling, slow thinking, pounding heart• Cause from• Oral hypoglycemic

• Tx• CHO, orange juice, sugar, candy, coke

• Risk• Insulin shock• Rapid onset

ENDOCRINE PHARM: THYROID

• Secretes T3 and T4 hormone• Hypothyroidism• Metabolic rate decrease, decrease mental and physical

stamina, increase weight• Tx: generally life-long replacement therapy• Synthyroid, Levoxyl, Armour

• Hyperthyroidism• Excessive heat, increase motor activity, increase sen

to pain• Epi contraindicated (NBQ)• Require higher doses than usual of sedatives,

analgesics, local anes• Tx: radioactive Iodine, kills thyroid cells w/out affecting

other cells

FEMALES SEX HORMONE

• Secretes: estrogen, progesterone• Know therapeutic uses and types• Used in contraception• Replacement therapy in post-menopausal

women• Premarin, Femert

• Side effects• Risk thromboembolic disease, blood clots,

hemorrhage

MALE SEX HORMONES

• Secretes – testosterone hormone• Androgenic: development of secondary male

sex char.• Androgenic steroids: used in tx of breast

cancer or replacement therapy• Anabolic steroids: results in tissue PRO and

nitrogen retention (treated as Schedule III controlled drugs – abuse potential)

ANTIBACTERIAL AGENTS

• Bactericidal: ability to kill bacteria, irreversible action• Bacteriostatic: ability to inhibit or slow the multiplication or

growth of bacteria• Minimum Inhibitory Concentration (MIC): lowest

concentration needed to inhibit visible growth of an org• Resistance: natural or acquired ability of an organism to be

immune to or to resist the effects of an anti-infective agent• Spectrum: range of activity of a drug• Synergism: Occurs when the combo of 2 antibiotics

produces more effect than would be expected if their indiv effects were added

• Antagonism: occurs when a combo of 2 agents produces less effect than either agent alone

ANTIBIOTICS

PENICILLIN• Tx and prevention of dental infections• Effective against 90% bacteria involved in dental

infections• Pen VK most popular, less erratic absorption then Pen G• Pen G: inactivated by gastric acids

• Amox used for prophylaxis regimen• Not effective against penicillinase: enz produced by some

bacteria which produced resistance• Derivatives: Amoxicillin, Ampicillin, Augmentin (amox &

clavulanic acid)• Work by destroying bacterial CELL WALL integrity which

leads to lysis• Most effective against rapidly growing org (Log Phase)

ANTIBIOTICS

PENICILLIN• Adverse effects / manifestations• GI distress / Candida• Anaphylactic rxn: greatest danger of pen use (NBQ)• Those allergic to pen = also allergic to

cephalosporin’s and all derivatives of penicillin• Most common allergic rxn = skin rash• CAN be given to pregnant women• Amoxicillin NOT effective against penicillinase (also

known as ‘beta lactamase’)• Clavulanic acid in combo w/amox (Augmentin) =

PREVENTS penicillinase from breaking it down

ANTIBIOTICS

TETRACYCLINE• Drug interactions, do not take with: dairy products,

antacids, iron tablets, calcium• Cause chelation of tetracycline's which reduces GI

absorption• Mixing tetra w/other antibiotics = results in

antagonism• Ability to concentrate in gingival crevicular fluid• Often used topically to tx aggressive perio d.• Inhibit collagenase production (may be used for

chronic perio• May be used systemically to tx NUG/NUP

ANTIBIOTICS

TETRACYCLINE• Bacteriostatic: work by inhibiting PRO synthesis

(not act on cell walls)• Previous boards• Antacids decreases up to 50% tetracyc• Ca-containing foods inhibit absorption• Know how to id tetracycline staining and how

occurs

ANTIBIOTICS

Macrolides• Erythromycin – 1st generation• GI effects

• Clarithromycin, Azithromycin (Zithromax) - 2nd

• Used to tx resp. inf.• Drug Interactions• Increase serum conc. of theophylline,

anticoagulants, digoxin, carbamazepine

ANTIBIOTICS

NITROMIDAZOLES• Ex: Metronidazole• Effective against obligate anaerobes ONLY• Due to anabuse-like rxn, alcohol should be

avoided • Mouthrinse

ANTIBIOTICS

SIDE EFFECTS• Most common: GI upset• Secondary: fungal infections • Allergic rxns

ANTITUBERCULOSIS AGENTS

• Transmitted through inhalation of infected bact• (-) test indicated no further testing• (+) indicated a chest x-ray• Sputum smear = most definitive test to

determine TB• 3 consecutive negative sputum smears

necessary to determine person w/ Hx TB no longer contagious

• PPD (purified PRO derivative) is an antigen used to aid in diagnoses of TB exposure = known as Mantoux skin test

ANTITUBERCULOSIS AGENTS

• Rxn measured in mm of induration at the site approximately 48-72 hours after PPD has been determined (NBQ)• Positive test does NOT indicate person has

active disease, only that they have been exposed to the disease (NBQ)

ANTITUBERCULOSIS DRUGS

• Rifampin• Red urine, tears, saliva

• Isoniazid• May lead to hepatoxicity

• Pyrazinamide• May lead to hepatoxicity

• Ethambutol• Decrease red/green color discrimination• Decrease visual acuity

• All 4 drugs used at same time to be effective

ANTITUBERCULOSIS DRUGS

• Pt indicates taking isoniazid or rifampin ONLY = Rx could be to prevent from developing TB• Rifater refers to a combo of isoniazid,

rifampin & pyrazinamide• Rifamate/Rimactane refers to combo

isoniazid, rifampin• Ethambutol also known as Myambutol• Streptomycin may be given in place of

ethambutol

ANTIFUNGAL AGENTS

• Candidiasis: candida albicans is a yeast like fungus• Common after ABXor steroid use and in

immunocompromised patients• Conditions contributing to disease• Xerostomia• Diabetes• Poor oral hl• Prosthetic appliances• Suppression immune system

• Tx• OTC: Nystatin (Mycostatin), Clotrimazole (Mycelex)• Stronger: Ketoconozole (Nizoral), Fluconazole (Diflucan)• Nystatin commonly used in dentistry

ANTIVIRAL AGENTS

• Colds, influenza, hepatitis, Epstein-Barr, Mononucleosis• Herpes Simplex Virus: cold sores• Acyclovir (Zovirax): will not cure, will help heal faster

• HIV• Zidovudine (AZT, Retrovir): Nucleoside Reverse

Transcriptase Inhibitor (NRTIs) was 1st drug approved for tx HIV

• Protease Inhibitors: Saquinavir(Invirase), Ritonavir(Norvir)

• Blocks some component of replication cycle of HIV which is classified as a retrovirus

• Know oral manifestations and management: Oral Kaposi’s sarcoma, hairy tongue, leukoplakia, papillomavirus, herpes

PREMED IN DENTISTRY

• 2007 AHA Guidelines• Need• Artificial heart vales• A hx of infective endocarditis• Cardiac transplant that develops valvular problems• Specific congenital heart defects such as

1) Unrepaired or incompletely repaired cyanotic congenital heart disease

2) Completely repaired congenital heart defect with prosthetic material or devise during the first 6 months after the procedure

3) Any repaired congenital heart defect with residual defect at the sire or adjacent to the site of a prosthetic patch or devise

PREMED IN DENTISTRY

• Those cardiac conditions NO LONGER requiring antibiotic premedication include:• Mitral valve prolapse (with or without regurgitation)• Rheumatic heart disease• Bicuspid valve disease• Calcified aortic stenosis• Certain congenital defects• Ventricular septal defect• Atrial septal defect• Hypertonic cardiomyopathy

PREMED IN DENTISTRY

• Oral antibiotic drug regimen for cardiac conditions:• If a patient is NOT allergic to penicillins,

administer:• Amox 2000mg (2g), 30min to one hour prior to

invasive procedure (calculate 50mg/kg for kids)• If patient is allergic to penicillins, administer:• Cephalexin: or other 1st generation oral

cephalosporin• Clindamycin• Azithromycin• Clarithromycin

PREMED IN DENTISTRY

• Prosthetic Joint Prophylaxis• Current premed guidelines by the ADA do not reflect

the views of American Academy of Orthopedic Surgeons (AAOS)

• Therefore, although current AAOS recommendations stipulate that prosthetic joint replacements require antibiotic premedication for life, the Board will likely use the ‘older’ guidelines listed below:• Joint replacement may be need antibiotic

coverage in the following cases:• Less than 2yrs following replacement surgery• Previous prosthetic joint infections• Multiple joint replacements

PREMED IN DENTISTRY

• Non-cardiac Medical Conditions• Much controversy• Renal dialysis shunt• Ventricular hydrocephalic shunt• NOT requiring antibiotic premed• Splenectomy• Lens and Breast Implants• Stents• Any procedure NOT producing much bleeding

• Non-Invasive Procedures: not needing premed• Block injections, Radiographs, Impressions, Sealant

placement, Fl tx

MISC BOARD MUST-KNOWS

• Corticosteroid meds such as Prednisone may lead to adrenal suppression• Statin drugs used to lower cholesterol include• Lipitor• Lescol• Mevacor• Livalo• Pravachol• Zocor• Crestor

MISC BOARD MUST-KNOWS

• HIV drugs • AZT• Didanosine• Zalcitabine• Stavudine• Laminivudine• HIV Pretease Inhibitors

MISC BOARD MUST-KNOWS

• Hypothyroidism• Most common tx = thyroid hormone replacement• Levothyroxine common = synthyroid• Levoxyl, Levothroid, Unithroid• Synthyroid dose too low=pt cold intolerant• Use caution w/ epi-containing anes • Myxedema coma may result if pt taken off synthyroid

suddenly• Iodine insufficiency may cause thyroid gland to enlarge

producing a goiter (iodine supplement often warranted)• Synthyroid• Given 1x/day due to long half-life• Toxicity indicated by nervousness, heart

palpitations/tachycardia, intolerance to heat

MISC BOARD MUST-KNOWS

• Pupil dilation sign of cocaine use• Alcohol in combo w/nitroglycerine will result in

dangerously low blood pressure• Flagyl (metronidazole) is an anti-infective agent that

has an anabuse-like rxn when used in conjunction w/alcohol

• HRT = linked to osteoporosis and gingival inflammation

• Pregnancy drugs that are acceptable = local anes, acetaminophen, clindamycin, nystatin

• Local anes = will NOT affect a nursing baby• NSAIDs decrease effectiveness of muscle relaxants

MISC BOARD MUST-KNOWS

• Zyban is an antidepressant used for smoking cessation• Chantix = non-nicotine med designed to BLOCK

nicotinic receptors in brain• SSRIs: selective serotonin inhibitors are a class of

antidepressants• Fluoxetine: Prozac, Prozac weekly• Sertraline: Zoloft• Citalopram: Celexa• Escitalopram oxalate: Lexapro• Paroxetine: Paxil, Paxil CR

MISC BOARD MUST-KNOWS

Estrogen• Steroid hormone• Estradiol is the most potent estrogen produced by women

(estrone, estriol have 1/10th the potency)• Common side effects: nausea, vomiting• May promote endometrial carcinoma and breast cancer in post-

menopausal women• May cause increase in gingival inflammation• Lowers LDL, increases HDL levels• Examples: Premarin, Estraderm• Frequently used for:• Contraception• Post-menopausal hormone therapy• Menstrual disturbances• Steroid hormone

MISC BOARD MUST-KNOWS

• Mevacor (Lovastatin)• Antihyperlipidemic agent• Inhibits HMG-CoA reductase and increases catabolism of

LDL

• Lipitor• Antihyperlipidemic agent which limits cholesterol

synthesis and increases catabolism of LDL• Been shown to decrease triglyceride levels• GI upset common• Can increase the anticoagulant effect of Warfarin

MISC BOARD MUST-KNOWS

• Prednisone• Intermediate-acting glucocorticoid• Dramatically reduces inflammatory response and suppresses

immunity• Increases risk of infection and delays healing• Symptoms of infection may be masked• Can exacerbate hypertension• Osteoporosis is common w/ long-term use• Adrenal crisis possible under stress: steroid supplementation

may be necessary if patient has been taking 5-10mg prednisone longer than 2 weeks – check with MD!!!

• Uses: autoimmune disease, Addison’s disease, Relief of inflammatory symptoms, Tx allergies

• Side effects: edema, Buffalo-hump, moon face, peptic ulcers, mental disturbances, increase body hair growth, insomnia