MEDICATIONS RELEVANT IN MH

Question 1

What is methotrexate and what is it used to treat? What relevance does it have?

Answer 1

Non-biological disease modifying anti-rheumatic drug (DMARDs)

Treats rheumatoid arthritis

It is an anti inflammatory and an immunosuppressant

• consider antibiotic prophylaxis (drug not routinely stopped for dental treatment)
• consider they have RA so risk of Sjögren’s syndrome or osteoporosis

Question 2

What are corticosteroids, give an example of one and what they treat. Any risks or possible issues with MH and dental treatment?

Answer 2

Cortisone, prednisone, hydrocortisone

Anti-inflammatory and immunosuppressant

Treat hay fever, asthma, arthritis etc

• reliance on these can cause hypothalamus-pituitary-adrenal axis suppression

This leads to inadequate production of cortisol leading to inadequate responses to body stress, invasive surgery or infection.

Question 3

What is apixaban? What used for? Any issues with regards to dental treatment?

Answer 3

DOAC - Anticoagulant used to inhibit factor Xa

Used to prevent blood clots and prevent strokes

For low bleeding risk procedures - no change to treatment or to drug regime

For higher risk bleeding procedures - delay drug (1 daily pill) or miss morning dose (2xdaily pill)

Question 4

What is miconazole? Dose? Any interactions?

Answer 4

Used to treat oral candidiasis or prevent oral candidiasis

Pea sized shaped twice daily and continue for ten days post clearing up

Heighten anticoagulant effect of warfarin, so should not be used

Question 5

What does Simvastatin do?

Answer 5

treat hypercholesterolaemia

Question 6

Furosemide?

Answer 6

loop diuretics, used with other hypertension drugs to reduce hypertension

Question 7

Carvedilol?

Answer 7

beta blocker to manage hypertension. Not a first line treatment, should consider hypertension in the treatment plan if patient is on this.

Question 8

Metformin

Answer 8

Anti-hyperglycaemic affect
- sensitise tissues to insulin

First choice treatment for all patients with diabetes

Can reduce vit b12, resulting in anaemia

Question 9

Sulfonylurea?

Answer 9

augment insulin production. Used as part of triple therapy.

This indicates patient has had trouble controlling their diabetes.

Question 10

What is warfarin? How does it work? What relevance to dentistry?

Answer 10

Inhibits blood clotting
- through inhibition of vitamin K dependant clotting factors

Patients INR should be checked no more than 24 hours before bleeding risk dental appt, it should be within 2-4 range

Question 11

What are apixaban, rivaroxiban and edoxaban and dabigatran?

How do they function?

Are there any considerations with dental tx?

Answer 11

All are direct oral anticoagulants that work through factor Xa inhibition

Dabigatran however is a direct thrombin inhibitor

For high bleeding risk procedures, patients should:

Miss morning dose of apixaban and dabigatran

Delay morning dose of rivaroxiban

Take normal evening dose of edoxaban

Question 12

How do statins work? What do they do?

Answer 12

Inhibit cholesterol synthesis in the liver by inhibiting HMG-coA reductive enzyme in early cholesterol synthesis

Question 13

What dental considerations must be made with statins?

Answer 13

Can interact with all dental antifungals

Stop statin while on dental antifungal
- resume once fungal course is finished

Question 14

How do beta blockers work? Any side fx?

Answer 14

Block effects of epinephrine to reduce blood pressure and heart contractile force

Fatigue, dizzyness, dry mouth

Question 15

Dental considerations of beta blockers?

Answer 15

They can mask the symptoms of hypoglycaemia in diabetic patients

Postural hypotension when sitting up, so move dental chair slowly

Epinephrine in LA probably not ideal for someone who wants to reduce epinephrine

Can enhance bronchospasm or asthma fx

Question 16

What are calcium channel blockers and how do they work?

Answer 16

Cause vasodilation and slow the heart rate

Act on the smooth muscle cells lining vessels and block calcium causing muscles to relax

Also affect heart conduction system to decrease frequency of heart beat

Question 17

Dental considerations of calcium channel blockers?
Any side fx?

Answer 17

Side fx - nausea and dizziness, swollen ankles and legs

Postural hypotension issue

Gingival hyperplasia - especially in amlodipine

Avoid giving LA worth adrenaline

Question 18

What are ace inhibitors? How do they work?

Answer 18

Inhibit conversion of angiotensin 1 to angiotensin 2 - a substance that narrows blood vessels

This leads to wider blood vessels and a decrease in blood pressure

Question 19

Dental considerations of ace inhibitors?

Answer 19

Postural hypotension again

Patients can have a persistent cough

Question 20

MOA ibuprofen

Answer 20

Inhibits COX1 and COX2 enzyme pathways, thus reducing the production of prostaglandins and reducing inflammation.

Question 21

MOA paracetamol?

Answer 21

COX1&2 enzymes metabolise arachidionic acid, creating hydroperoxides

These HPs further upregulate metabolism of arachidonic acid and release of prostaglandins.

Paracetamol blocks this feedback loop resulting in

Analgesia,
Antipyrexia

Question 22

MOA chlorhexadine

Answer 22

Binds to negatively charged components of the cell wall of the microorganism

Alters permeability of cell membrane, thus causing leakage of intracellular components leading to cell death.

Question 23

MOA PenV?

Answer 23

Primarily against gram+ - narrow spectrum

Binds to penecillin binding proteins in bacterial cell wall inhibiting synthesis of peptiodglycan

This results in weakening of the cell wall, and an inability of the cell to synthesise and maintain its cell wall, leading to lysis.

Question 24

MOA metronidazole?

Answer 24

Anaerobic bacteria - low O2 environments

Taken up by anaerobic MOs

Metronidazole is reduced within the cell producing free radicals and toxic metabolites

These disrupt DNA structure of the MO and can break DNA strands and thus inhibits synthesis of proteins and further DNA essential for cell function

Question 25

MOA fluconazole?

Answer 25

Used for systemic fungal infection

Inhibits synthesis of ergestorol - essential component of cell membrane of fungus

Disrupting integrity of cell membrane leads to lysis

Question 26

MOA nystatin?

Answer 26

Binds to ergestorol and forms pore in cell membrane of fungus, leading to cell lysis.

Different to Azoles and binds to ergestorol does not inhibit its production

Question 27

MOA miconazole?

Answer 27

Topical fungal

Inhibits synthesis of ergestorol at the site of application. Ergestorol essential component in fungus cell membrane, leading to lysis.