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 children’s doses is included where

appropriate.

prescription?the How to write

� 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.

� (e.g. strengthand form of the drug, its namegeneric The 4.

.)200mg tablets flagel200mg tablets metronidazole

� 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 prescriber’s 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 prescription-

p-14-

� The ❶: 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 ❷: 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 ❸: 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.

� ) so if u polypharmacyThe elderly patients take many medication(-

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).

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.

most antibiotic

enhance the effect of

warfarin

Drug that’s 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.

� Some drugs pass into the milk and are thereby Breast feeding :♣

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.

� the liver. byMany drugs are metabolized : Liver disease♣

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.

� Nephrotoxic drugs should be avoided such as : Kidney disease ♣

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 don’t 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

.DsNSAI

� Eg; aspirin and ibuprofen, other examples: voltaren(diclofenac

sodium), indomethacin( it has high risk to pregnant ladies because

.)arteriosusus duct t may cause closure ofI

� -And this is generalizes for all NSIADs so we don’t give them to

.in third trimesterpregnant ladies

� ."Naprelan"name commercialwhich has naproxen Also we have

� 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.

---------------------

?sAIDare at risk of NS sWhat patientQ;

� ;Peptic ulceration-1

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

NSIADs:

non-

steroidal

anti-

inflammat

ory drugs

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.

;Bleeding disorders-2

effect antiplatelet permanentWe know that aspirin causes

such as sSAIDother N, but ityracto eletit has good plat ausebec

antiplatelet temporaryen and others they cause only ibuprof

if we doing a major surgery,,, how many days we so effect,

should stop the aspirin before the surgery??... 10 to 12 days.

effect, so we wait until the permanentBecause it has Why??

en prof , butplateletsand makes new the platelet spleen degrade

.we should wait only 2 to 3 days

;coagulant-Anti-3

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.

Children; -4

under the age of 12, aspirin is contraindicated, why?? Because

they is a risk of Reye’s syndrome( liver degeneration,, which is

fetal).

But profen and others can be given to patient older than one

year.

;Asthmatics-5

- 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.

;regnancyP-6

-in pregnant ladies as we said in 3rd trimester it might prolonged

the labor, bleeding at birth, Early closure of ductus arteriosus(

Indomethacin).

;Renal or hepatic disease-7

� 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

Reye’s 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.

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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 don’t 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 1-

2*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).

in the past there was plenty of Prophylaxis of endocarditis:

indication of infected endocarditis "NICE" and "AHA guidelines"

NICE; British guidelines don’t indicate prophylaxis antibiotic for all

patients,, there is no need for antibiotic prophylaxis at all. It’s a

new guidelines for British guidelines.

Heart Americanis we adapt to American school which But

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 .

SI(surgical sign infection):Prophylaxis against S

-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 it’s 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.

: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.

300mg 1*3-: 150 Clindamycin▪

-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 !!

Amoxyclav=

amoxicillin+

clavulanic acid

-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♣

.0.2% M.W-(mostly) 0.12Chlorhxidine▪

� -M.W, Irrigation, toothpaste…

� -SE staining.

%Iodine 1-Povidone▪

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.

بارك هللا لي ولكم.

Done by; Asmaa almawas

reading-Self

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

four hours q.q.h : every

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.

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