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Part/2;

DRUG PRESCRIBING
BNF (British National Formulary); -Is an essential source of information on drug actions, uses and dangers. -Within the BNF there is a list of drugs which may be prescribed by dentists. -Doses quoted in the BNF are the normal or accepted adult dose[for adult normal patient]and we can manage for children. -Guidance on suitable childrens doses is included where appropriate.

How to write the prescription?


1.Name of patient; should be clear at the top of the prescription. 2. Age of patient; its v.imp especially in children. 3.Total number of days of treatment.

4.The generic name of the drug, its form and strength (e.g. metronidazole tablets 200mg flagel tablets 200mg).

5. Instructions as how and when to use the drug(after, before, within the meals, one ,two three times daily)written in English with no abbreviations (e.g. one tablet to be taken three times daily with food). 6. Delete any space remaining on the form with vertical and horizontal lines. 7. Date and prescribers signature.

This is example how to write the content of the prescription: of-course at the top

there is the name of the pt, his/her age and the name of our institution, then the content;

The RX; symbol we always try to put in the top of the prescriptionp-14The : amoxicillin(antibiotic) which is the name of the drug in generic, the strength is 500 mg, its capsules. There is many technique for how and when to use the drug, here the Dr used to write the number of tablets first which is -1- then the frequency-3 times- then duration for -7- days. The : Ibuprofen 400mg tablet, 1 tablets 3 times for 5 days and usually we write the analgesics as PRN(which is mean "as needed" from Latin word "prolenata" . The : chlorhxidine: mouthwash the percentage 0.2 once 3 times for 7 days. At the end; close any remaining space and sign with ur name.

The content of the prescription is the responsibility of the clinician not the pharmacist. ------------------------------------------------------------------------------------

PATIENTS AT PARTICULAR RISK


Children

-Doses for children should be appropriately reduced by age(roughly) or body weight(which is better).

-Roughly at the age, we usually from 6-12 years we half the adult dose, bellow 6 years we quarter. -but more accurate to calculate the dose according to the weight; eg; we consider adult patient 70kgs, for pediatric pt weight 30 kgs we give them half dose, if weight 10 kg we give him 1/7 of the dose.

-Children have some difficulty in swallow the tablet, so we prefer Elixirs/Syrups which is preferable for oral ingestion. -And we try to use Sugar-free preparations for children when available to minimize the risk of dental caries.

Elderly
-We should take care about elderly because they have slow metabolic rate, so the doses should be reduced, or some drug maybe contraindicated. -Gastrointestinal Hemorrhage is more common in the elderly pts. So when we are taking about NSAIDs which are analgesics more commonly prescribe by dentist it might cause bleeding in the elderly patients. -The elderly patients take many medication(polypharmacy) so if u give them analgesic or antibiotic it might do antagonistic effect with his medications or enhance warfarin for example.

Pregnancy
-Only prescribe when absolutely essential. -Use the safer preparations(category A, B).

most antibiotic enhance the effect of warfarin

There are categories of drug and their relation to pregnant woman, they are categories to A, B, C, D, X. A: it's safe totally, in vivo and vitro, this medications are very rare. B: it's safe in vitro, but not improved in vivo. SO A and B can be used safety in pregnant ladies. Eg; paracetamol its category B, amoxicillin its category B both are safe.

Drug thats under category C; cant prescribe unless her Dr approval. Some medications cause Teratogenic effects are most likely in the first trimester, in the second and third trimesters it may cause developmental abnormalities to the fetus.

Breast feeding :Some drugs pass into the milk and are thereby
ingested by the baby, so we should know its effect on the baby its harmful or safe( if it's safe we can prescribe it to the breast feeding mother and vice versa. Eg; the opioids which is passes to the milk and should not prescribe to breast feeding mother. Another example tetracycline which is antibiotic should not be given to breast feeding ladies because it cause staining specially to the anterior teeth.

Liver disease : Many drugs are metabolized by the liver.

Impaired liver function(cirrhosis or any patho-necrotic) may affect the breakdown of drugs, so the drug might accumulate and causing toxic effect to the patient, so we try to give the pt drug that not metabolize in the liver, eg; paracetamol metabolize in the liver, we give the pt codeine or NSAIDs instead of.

Kidney disease : Nephrotoxic drugs should be avoided such as


aminoglycosides which should be avoided in pt do dialysis, other safe drugs may require dose reduction according to the degree of impairment either halving the dose or type of the drug. In all of this cases we should know that we dont live at this universe alone, we try to consult the related physician, in the kidney disease we try to consult the nephrologist to ask about safer medication, what's the dose, and when to do the surgery, the same apply for liver disease and pregnant and breast feeding woman asking her Dr is very important. -------

Analgesia; every patient who need MOS or simple extraction needs analgesics at least paracetamol but more commonly we used

NSIADs: nonsteroidal antiinflammat ory drugs

NSAIDs.
Eg; aspirin and ibuprofen, other examples: voltaren(diclofenac sodium), indomethacin( it has high risk to pregnant ladies because It may cause closure of ductus arteriosus). -And this is generalizes for all NSIADs so we dont give them to pregnant ladies in third trimester.

Also we have naproxen which has commercial name "Naprelan". Q; why we prescribe NSAIDs commonly more than other analgesic?

-Because it has effect that is more preferable to surgeon, it has analgesic effect, it has anti-inflammatory effect and has antipyretic effect which is good in cases of infection. -Most of analgesic interfere with the production or conversion of arachidonic acid to prostaglandins(COX inhibitors). -We should know the mechanism of NSAIDs, some of them are cox1 inhibiter, some are generalize cox inhibitor such as aspirin and ibuprofen, they are not selective cox they are cox inhibitor. -ibuprofen mostly used at dosage of 400mg or 600mg TID(3 times in the day), For short term use. ---------------------

Q; What patients are at risk of NSAIDs?


1-Peptic ulceration;

We should ask each patient about some sort of diseases before prescribing NSAIDs; one of them and the most important one is peptic ulceration,, because ibuprofen and other NSAIDs cause inhibition of the prostaglandins which increase acid production in

the stomach and decease mucin in the stomach which increase bleeding from peptic ulcers or may cause perforation, so It's important not to prescribe this medication in peptic ulcer patients. 2-Bleeding disorders; We know that aspirin causes permanent antiplatelet effect because it has good platelet toracity, but other NSAIDs such as ibuprofen and others they cause only temporary antiplatelet effect, so if we doing a major surgery,,, how many days we should stop the aspirin before the surgery??... 10 to 12 days. Why?? Because it has permanent effect, so we wait until the spleen degrade the platelet and makes new platelets, but profen we should wait only 2 to 3 days. 3-Anti-coagulant; such as warfarin, which can be enhanced by all NSAIDs, so if the pt in warfarin and he takes as example profen u will see that INR is elevated so there will be increase bleeding tendency. 4-Children; under the age of 12, aspirin is contraindicated, why?? Because they is a risk of Reyes syndrome( liver degeneration,, which is fetal). But profen and others can be given to patient older than one year. 5-Asthmatics; - we ask all patient about asthma, asthmatic patient if we give them NSAIDs they might have hypersensitivity attack and acute severe bronchospasm which is an emergency. So we cannot give NSAIDs to asthmatic patients especially in uncontrolled patients.

6-Pregnancy; -in pregnant ladies as we said in 3rd trimester it might prolonged the labor, bleeding at birth, Early closure of ductus arteriosus( Indomethacin). 7-Renal or hepatic disease; Renal disease reduce dose or avoid NSAIDS because some of them are toxic to renal tubules. Liver diseases may enhance bleeding because all liver disease patient has increase bleeding tendency.

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Paracetamol
-The most common drug that we prescribe for simple pain, it has similar analgesic properties to aspirin, its good antipyretic, but it has little or no anti-inflammatory action, it's good for peptic ulcer patient, it has no significant GI irritation, and it's not implicated in Reyes syndrome. -The most imp thing is the: Dose : (500mg or 1g) orally -4 times daily(4-6 hour). Maximum adult dose 4 g daily, if the pt ingest more than 7 to 8 g in day which is toxic dose, the patient should admitted to gastric lavage because it's a toxic dose to the liver. -We can use IV paracetamol "perfalgan" in some cases such as pregnant ladies with sever acute pain. ------

Opioids
-Causes Depression of pain center.(not like NSAIDs which work peripherally).

- it causes Stimulation of vomiting, salivation which are the parasympathetic way. - cause Dependence (addiction); many times we see patient seeking opioids for dental pain which is very common!!, tramadol for dental pain as example but they addict to this drug. -Other problem with opioid which is the Tolerance, patient continue more than 2 weeks on opioids he might dont give the desired effect of the opioids, he might need increase the dose,, which we call it tolerance. - it might cause Constipation. Examples: -Codeine ; mostly mixed with paracetamol as Revacod 500mg 12*3 . -Tramadol (Tramal); -opioid like analgesic -50-100mg 1*3 PRN( to don't cause addiction).

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Antibiotics
-Antibiotics are given to prevent (prophylaxis) or treat infection (Therapeutic). -Different types and spectrum for pharmaco- dynamics &kinetics.. -The wide use of antibiotics may cause Resistance ! -Side effects: 1-allergy(maybe fetal to the patient). 2-G.I disturbance(diarrhea.)

3-super-infections(fungal as thrush or bacterial as pseudomembranous colitis).

Prophylaxis of endocarditis: in the past there was plenty of


indication of infected endocarditis "NICE" and "AHA guidelines" NICE; British guidelines dont indicate prophylaxis antibiotic for all patients,, there is no need for antibiotic prophylaxis at all. Its a new guidelines for British guidelines. But we adapt to American school which is American Heart association 2007(AHA) they minimize number of patients into 4 small categories; Patients At Risk: (AHA 2007) 1-history of infective endocarditis 2-Cardiac prosthetic valve replacement 3-A heart transplant with abnormal heart valve function 4-Some congenital cardiac defects (Cyanotic). These are actually very young and we see them in the pediatric section. Antibiotic regimens;

This is the regimens of antibiotics, previously it was 3 g amoxicillin, now its 2gs,,, generally we give the patient 2gs amoxicillin it means 4 capsules one hour before the procedure if he is allergic we give him clindamycin 600mg orally, or IV 1g cefazolin or ampicillin IV. This is very simple, only give the patient 2g amoxicillin one hour before the procedure .

Prophylaxis against SSI(surgical sign infection):


-It's Not indicated in most of cases!! -It Might be indicated in cases like immune- compromised patients(eg; diabetic). -Generally it is considered in contaminated wounds not the clean or clean-contaminated ones, which means in extra oral surgeries which is clean surgery, so no role of antibiotic treatment, but intra orally, its consider a clean contaminated because of saliva. Sometimes if there is pus or foreign material we consider it dirty, so we might prescribe antibiotic, let say for extraction of present periodontitis or pericoronitis so we can consider antibiotic in such case.

Treatment of infection;
-Ideally antibiotics must only supplement drainage. What the treatment of abscess? Incision and drainage. What the treatment of acute periapical abscess? Access What the treatment of gingivitis? Scaling and oral hygiene. -There is no role for antibiotic,, only supplemental of these in certain people

Indications for ABx:


-Systemic manifestations as fever, malaise, lymphadenopathy. -Cellulitis with rapid spread of infection.

-Involvement of fascial spaces, trismus, dysphagia, with risk on airway or vital structures as eyes. -Inadequate drainage though its not an excuse! -Immuno-compromised Pt.

Examples on ABx:

Penicillins:
-Amoxicillin ; Ampicillin oral 500mg 1*3

-Flucloxacillin for Staph(in salivary gland infection such as ascending sialadenitis, most of them are mix staph and strep 250mg 3 to 4 times daily -Augmentin( co amoxiclav) 625mg 1*3(given 3 times daily), For children 375 mg 1*3. this is the oral preparation, For IV 1.2 mg for fascial space infections.

Amoxyclav= amoxicillin+ clavulanic acid

Metronidazole:
-Flagyl for anaerobic bacteria and parasites. -the dose; 250-500mg 1*3daily, We can supplement in abscess amoxicillin +flagyl together,, in cases of pericoronitis flagyl is the gold standard in treatment.

Clindamycin : 150-300mg 1*3


-for mix infection aerobes and anaerobes -for penicillin allergic pts( if the pt hypersensitive to penicillin we shift into clindamycin or cephalosporin, but mostly clindamycin because cephalosporin has 10% cross sensitivity with penicillin, so one of 10 pts might have double sensitivity to cephalosporin and penicillin). -if pts take for a long period of time clindamycin this may lead to "antibiotic associated colitis".

Cephalosporin :
-10% cross sensitivity as penicillin !!

-it has 4 generations, it mostly used by dental uses. ex : cephalexin 500mg 1*3 cefuroxine 1gm IV/IM cefutaxime 1gm IV/IM.

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Antifungals
Miconazol: For oral candidiasis and angular chelitis though it is effective against S. Aureus. Oral gel 25mg/ml 2-5 ml 1*4.

Cream 2%(extra orally at the angel of the mouth) 1*3. Fluconazole: -given systematically or oral capsules. -50-100 mg capsules daily for 2 weeks at least. -----------------------

Antivirals
Acyclovir: -For herpes infections(herpes simplex or zoster).

-Topical cream 5% 1*4 on the lips at the podrum symptoms.

-Oral preparation called Zoverax 200-800 mg daily for 10 days. --------------------------

Mouth washes
Chlorhxidine(mostly) 0.12-0.2% M.W.

-M.W, Irrigation, toothpaste -SE staining.

Povidone-Iodine 1% C/I Thyroid pts diseases. ---------------------------------

Oral ulcerations
What's the most common ulcers in the mouth?- recurrent Aphthous ulceration. What are the main medications? 1-Either we used Coating agents: #Solcoseryl dental gel 1*3

#Aloclair dental gel/ M.W 1*4

-These are coating agent we apply it on the ulcer 4 times daily it coat the ulcer and prevent the environment from getting pain into the ulcers. 2-We use this after the meals, before the meals if the pt have severe pain we use anesthetic M.W such as: #Lidocaine M.W or Spray (Trachezan)

#Benzydamin HCL: 0.15% M.W 1*4 (Tantum Verde) 3-Steroids: cream/M.W/spray #Hydrocotison cream1% 1*3. #Triamcinolone gel 0.1% 1*3.

Steroids uses should be less than 1 week to prevent super infections.

. Done by; Asmaa almawas

Self-reading Rx theory: "The symbol Rx is derived from the major lines in the symbol of the Eye of Horus. Horus was an Egyptian god, the god of Nekhen, a village in Egypt, and god of the sky, of light, and of goodness. He was the son of Isis, the nature goddess, and Osiris, the god of the underworld. Osiris was murdered by his evil brother Seth, the god of darkness and evil. Horus sought to avenge his fathers death by challenging his uncle Seth to a fight. Seth cut out Horuss eye, but Thoth, a god associated with wisdom and compassion, magically restored the eye. Horus did defeat Seth, finally. Horuss eye, also called the wadjet eye, became a symbol for health. The Egyptians considered it a symbol of good and restored health."
Latin abbreviations. a.c. : Before meals b.d. : Twice daily o.d. : once daily o.m. : every morning o.n. : Every night p.c. : after meals )p.r.n. : as needed (important to know q.d.s : four times a day q.q.h : every four hours stat: immediately (emergency) so in case a person got into a car accident, he needs a lot of fluids, we would write 1 liter normal .saline stat over 15 min 35 t.d.s : three times a day

ps: Always use the dosage that minimizes any misunderstanding between you, the pharmacist, and the patient. - you should always abide the law and regulations. Every country has its own regulations regarding medications

prescribed for many reasons like to prevent getting addicted to a certain medicine - Controlled Drugs Controlled drugs are drugs that can be addictive. Let's say a patient has had a major procedure and needs a very strong anesthesia like Tramadol, a pain reliever used to treat moderate to severe pain. Tramadol has to be prescribed on a separate

,piece of paper, so the prescription can't include antibiotics


tramadol, and other medication.