mda : ch-30 mda : ch-30 dent-215 seema jain copyright c 2005, 2002, 1999, 1995, 1990, 1985, 1980,...
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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
Copyright C 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Elsevier Inc.
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.
Copyright C 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Elsevier Inc.
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
Copyright C 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Elsevier Inc.
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.)
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.
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
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!
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.
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
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
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
Components (2)
Inscription Contains the name and amount of each
medication Avoid abbreviations and indicate
amounts in metric
Lotta CelivaAdultYou decide (pharmacist often fills this out for you)
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.
Lotta CelivaAdultYou decide (pharmacist often fills this out for you)
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
Atropine sulfate 0.4 mg
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"
Copyright C 2005, 2002, 1999, 1995, 1990, 1985, 1980, 1976 by Elsevier Inc.
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
Atropine sulfate 0.4 mg
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
No Your Name, DDSYour Name, DDS
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
No Your Name, DDSYour Name, DDS
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?
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.
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?
???????
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Anxiety and Pain Control
A technique of various psychological, physical, and chemical approaches to
prevent and treat preoperative, operative, and postoperative anxiety
and pain.
Copyright © 2005 by Elsevier Inc. All rights reserved.
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
Copyright © 2005 by Elsevier Inc. All rights reserved.
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
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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
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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.
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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.
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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.
Copyright © 2005 by Elsevier Inc. All rights reserved.
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.
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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.
Copyright © 2005 by Elsevier Inc. All rights reserved.
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.
Copyright © 2005 by Elsevier Inc. All rights reserved.
Commonly Prescribed Sedatives
Secobarbital sodium (Seconal) Chlordiazepoxide HCl (Librium) Diazepam (Valium) Chloral hydrate (Noctec): For
children
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Intravenous Sedation
Antianxiety drugs administered intravenously throughout a procedure at a
slower pace, providing a deeper stage I analgesia.
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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.
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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
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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.
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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.
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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
Copyright © 2005 by Elsevier Inc. All rights reserved.
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
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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
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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.