Medicines & Therapeutics Flashcards
What are the 4 medication subtypes most commonly used in oral medicine?
- antimicrobials
- topical steroids
- benzdamine mouthwash
- carbamazepine
What subcategories of antimicrobials are used in oral medicine?
- anti-virals
- anti-fungals
- antibiotics
What type of antimicrobial is most commonly used in oral medicine?
anti-fungals and anti-virals
- most commonly fungi and viruses producing acute or chronic oral disease
What two types of topical steroids are used in oral medicine?
- inhaled steroids
- steroid mouthwash
What is carbamazepine used for?
management of facial pain
What are the 5 classifications of medications?
- general sales
- pharmacy medicines
- prescription only medicines
- controlled drugs
- medical devices
Which classification do most dental medicines fit into?
- pharmacy or general sale
What classification of medicines are antimicrobials?
- prescription only
What are controlled medicines?
medications with specific legislations restricting prescription, possession and use, sometimes used in oral medicine
Give an example of a medical device used in dentistry
saliva substitutes
What are licensed medicines?
medicines which have been proven in evidence to the MHRA to have efficacy and safety at defined doses in a child and/or adult population when treating a specified medical condition
they are subject to post licence surveillance via the MHRA
What is the MHRA?
Medicines and Healthcare products Regulatory Agency
Can a medication only have one licensed purpose?
Medications can gain further licences for additional uses by subjecting to clinical trials and post licence surveillance
What are unlicensed medications?
medicines that have not have any evidence of efficacy submitted for the condition under treatment?
What must be carried out when prescribing an unlicensed medication?
- must be licensed for another condition
- use is at the discretion of the treating physician
- patient must be aware of the off-licence use
- patient must be provided with a PIL specific to the treatment being carried out
What are the licensed and unlicensed uses of colchicine?
- licensed
- treatment of gout
- unlicensed
- treatment of oral ulceration
What antiviral is used in oral medicine and what is it used to treat?
- aciclovir
- primary herpetic gingivostomatitis
- recurrent herpetic lesions
- shingles (recurrent herpes zoster)
What antifungals are used in oral medicine and what are they used to treat?
- miconazole, fluconazole and nystatin
- acute pseudomembranous candidiasis
- acute erythematous candidiasis
What topical steroids are used in oral medicine and what are they sued for?
- betamethasone mouthwash
- treat aphthous ulcers and lichen planus
- unlicensed for this purpose
- treat aphthous ulcers and lichen planus
- beclomethasone metered dose inhaler
- treat aphthous ulcers and lichen planus
- unlicensed for this purpose (asthma)
- treat aphthous ulcers and lichen planus
How are beclomethasone inhalers used in oral medicine?
- for treatment of aphthous ulcers and lichen planus
- inhaler nozzle held over affected area
- puff delivers steroid powder
- powder only present in desired area
What must be given to a patient that has been prescribed an unlicensed medication?
- specific patient information leaflet for unlicensed use
- standardised leaflets available to print
- recommend throwing out old PIL
- put new PIL in medication box
What are medical devices?
a product which does not achieve its primary intended by pharmacological, immunological or metabolic means
Why are artificial salivas considered medical devices?
they replace missing saliva and do not achieve this by pharmacological, immunological or metabolic means
Provide examples of salivary substitutes that are regularly prescribed in primary care
- saliva pastilles
- saliva orthana
- biotin oral balance
- artificial saliva DPF
- glandosane
What types of medications are used in oral medicine which cannot be prescribed in primary care?
- tricyclic antidepressants
- gabapentin/pregabalin
- azathioprine
- mycophenolate
- hydroxychloroquine
- colchicine
What are tricyclic antidepressants used for in oral medicine?
tricyclic antidepressants, such as amitriptyline and nortriptyline, are used to manage oro-facial pain as they work centrally in the CNS to reduce pain transmission.
What are gabapentin and pregabalin used for in oral medicine?
management of pro-faical pain in case of neuropathic pain where there is damage to the nerves
What immunosuppressants are used in oral medicine and when are they used?
azathioprine and mycophenolate
- used to treat inflammatory and immunological mucosal conditions where simple treatments have failed
What immune modulators are used in oral medicine and when are they used?
hydroxychloroquine and colchicine
- used to treat inflammatory and immunological mucosal conditions where simple treatments have failed
What type of medications are commonly used to treat lichen planus and why?
- anti-fungals and topical steroids
- overlying fungal infection
- underlying immunological change
What must be considered when prescribing a medication?
- clinical indication
- what is the most appropriate medication
- licensed or unlicensed?
- if a licensed drug is available it should be used
- dose and route of administration
- different for each patient
- warnings for patient
- interactions
- e.g. anti-fungals and statins
- e.g. metronidazole and alcohol
- cautions
- interactions
- treatment duration and monitoring
- immuno-modulating drugs
- regular blood tests at clinic or GP
- immuno-modulating drugs
Who must write a prescription for the patient?
- best practice is dentist writing prescription
- other staff members can write it
- prescribing dentist must sign
What details must be included on a prescription?
- patient name, address and age
- patient DoB and CHI
- number of days of treatment
- drug to be prescribed
- drug formulation and dosage
- instructions on quantity to be dispensed
- instructions to be given to the patient
- signature of prescriber
Discuss prescription validity
- valid 6 months from date issued
- can have more than one item on a script
- best practice to do individual
- one prescription can allow repeat dispensing
What are important points for writing a prescription?
- must be legible
- dentists cannot prescribe on computers
- write full instructions in ink
- avoid abbreviations
- dentist must sign prescription
- if not written by dentist, they must first check for any errors
- private prescriptions should include GDC number of prescribing dentist
- should be in identifiable prescription paper
What are the advantages of written instructions for patients?
- reminder for patient once they are home
- many patients will be stressed
- may not remember instructions given
- help to overcome language issues
- multilingual options
- large print options
- contact number for patients
- emergency contact for 24/7 access
- in case of any issues
- legal protection
- document that patient was given leaflet
- protection if post-treatment course questioned
What advice should be given to patients on prescription of medication?
- take medicine at correct time every day
- always finish the course
- stop taking medication in case of unexpected reactions
- contact prescriber
- discuss known side effects
- e.g. metronidazole and alcohol
- keep medicines safe
- keep out of reach of children
What guidance should be followed for prescribing drugs for mucosal disease?
SDCEP Drugs in Dentistry
What are the two sections of SDCEP drugs in dentistry relevant to mucosal disease?
- non-seteroid topical therapy
- for inconvenient lesions with discomfort
- steroid topical therapy
- for disabling immunologically driven lesions
What non-steroidal topical treatments are available for oral mucosal lesions?
- chlorhexidine mouthwash
- can be diluted 50% with water
- benzdamine mouthwash or spray
- topical anaesthetic for pain relief
- OTC remedies
- iglu
- listerine
- bonjela
What non-steroid topical treatment should be avoided?
- anything the patient finds helpful can be used
- check it is not harmful
- e.g. bleach, aspirin
- check it is not harmful
What steroid based topical treatment of oral mucosal lesions are available?
- hydrocortisone mucoadhesive pellet
- betamethasone mouthwash
- beclomathasone mouthwash
How are hydrocortisone mucoadhesive tablets used?
tablet placed on ulcer and allowed to dissolve
How is betamethasone mouthwash used?
- unlicensed product for oral mucosal lesions
- tailored PIL required
- betnesol 0.5mg tablets
- 2 tablets (1mg)
- 2 tsp water (10ml)
- 2 minutes rinsing
- twice daily
- do not swallow
- do not rinse after use
- no eating/drinking for 30 minutes after use
What advice must be given in the patient information leaflet for betamethasone mouthwash?
- accepted and proven effective treatment for condition
- licensed for other medical conditions
- for use in age 12 and above
- use with caution below 12
- dose frequency and use
- hazards of exceeding standard dose
- safe to use as directed
- no standard steroids side effect risk
- diabetes, osteoporosis, adrenaline suppression
- no steroid card needed if used properly
- known side effects
- small risk of oral candida
- special instructions
- spit out to avoid systemic steroid effects
- don’t rinse mouth after use
How is beclomethasone metered dose inhaler (MDI) used?
- unlicensed product for oral mucosal lesions
- tailored PIL required
- 50mcg/puff device
- position device correctly
- exit vent directly over ulcer area
- 2 puffs
- 2-4 times daily
- don’t rinse after use
- position device correctly
What type of beclomathasone MDI must be prescribed?
pressurised device
- not breath activated device
What advice must be given in the patient information leaflet for beclomethasone MDI?
- accepted and proven effective treatment for condition
- licensed for other medical conditions
- asthma
- COPD
- licensed for other medical conditions
- dose range and frequency
- technique used for oral lesions
- different from lung conditions
- known side effects
- small oral candida risk
- special instructions
- do not rinse mouth as effect will be lost
What systemic treatments are used only by specialists in oral medicine?
- disease modulators
- colchicine
- steroids
- prednisolone
- immune surpassants
- hydroxychloroquine
- lichen planus
- azathioprine
- mycophenolate
- hydroxychloroquine
- immunotherapy
- adalimumab
- enterecept
What is prednisolone used for in oral medicine?
- pulsed for intermittent troublesome ulcers
- high dose in short duration
- 30mg for 5 days
- cannot be used too frequently
- once each month
- high dose in short duration
What is is systemic steroid risk and when does its become relevant?
- can occur for prolonged courses or repeated short courses over many months
- 3 months continuous
- gaps of 2 weeks or less between pulses
- adrenaline suppression
- steroid dependancy
- do not stop suddenly, taper dose
- Cushingoid features
- osteoporosis risk
- bone prophylaxis
- Ca supplements and bisphosphonates
- DEXA bone density scan
- osteoporosis risk
- peptic ulcer risk
- proton pump inhibitor prophylaxis
- mood/sleep alteration
- very quick onset
- mania/depression risk
- very quick onset
Why must caution be taken for systemic treatments such as immune suppressants and immunotherapy?
- infection risk
- cancer risk
- adverse drug reactions
- only for use by a specialist in communication with GP as may be medical issues the OM specialist is unaware of
What screening must be carried out for patients in preparation for systemic immunomodulatory treatments?
- blood borne viruses
- hepatitis B
- hepatitis C
- HIV
- full blood count (FBC)
- electrolytes
- liver function tests
- thiopurine methyltransferase (TPMT)
- only for azathioprine use
- zoster antibody screen
- epstein-barr virus screen (EBV)
- chest x-ray
- evidence of previous or active tuberculosis (TB)
- cervical smear up to date
- pregnancy test
Why must patients be screened in preparation for systemic immunomodulatory treatments?
must ensure that immunosuppression will not harm the patient and that there are no pre-existing medical conditions which have not yet been detected
What does the planning of immunomodulatory treatment involve?
- full consent from the patient
- alternative treatment options discussed
- patient information given and patient reviewed
- short term risk
- acute drug reaction
- long term risk
- cancer risk increased
- especially azathioprine and skin cancer
- cancer risk increased
- effective contraception used
- pregnancy planned with clinical care team
- short term risk
- treatment outcome understood by patient and clinician
- complete remission
- acceptable level of symptoms
- trial treatment
- 6 months then reassess benefit and need for treatment
