Pharmacology Flashcards
1
Q
What would happen if we didn’t use anaesthetic or analgesics?
A
Patients would gain dental phobia and would avoid the dentist.
2
Q
What are ‘alternative’ techniques of pain/anxiety control?
A
Psychotherapy Accupuncture Hypnosis Pet therapy Systematic desensitization
3
Q
What is MDAS and why is a score of 19 significant
A
Modified dental anxiety score used to screen for IVS. 19 or above = phobia
4
Q
If a patient is going to have IVS, what do they need to bring with them? What happens if they don’t?
A
An escort and to not be left with children, drive or operate heavy machinery for 24 hours. They cannot have the surgery if they do no have this.
5
Q
What is the commonly used anaesthetic and what cartrages do we used?
A
Lidocaine/Lignocaine/Xylocaine 2%
1: 80,000 adrenaline
2. 2ml cartrages
6
Q
Why should we be careful using LA for hemophiliacs?
A
ID blocks are done in the pterygoid plexus which has lots of blood vessels which can lead to excess bleeding with reduced clotting ability.
7
Q
What are some contraindications LA
A
-If we are going into acute inflammation e.g. abscess (OK for regional block)
-Hemophiliacs or reduced clotting
-Allergies
-dontnneed it
-pregnant with felypressin
-
-
8
Q
What can we use to ease the pain of an injection
A
Ethyl Chloride or topical lidocaine 5%
9
Q
Where can we use infiltration’s for anesthetic?
A
Where there is porous bone and high vascular channels. In the maxillary teeth and possibly the posterior mandibular teeth.
10
Q
What happens if we can not use infiltration’s?
A
we use a nerve block
11
Q
What are the syringes we use in the dental hospital
A
Ultra safety plus - Singlue Use, self-aspirating
12
Q
Why and When do we aspirate?
A
In every injection. to ensure we are not in the blood vessel and if we injected into the blood stream it would have systemic affects and adrenaline would cause heart palpitations
13
Q
What types of aspiration do we have for LA?
A
Positive aspiration = actively pull back the plunger
Passive aspiration = release of pressure leads to aspiration
14
Q
Describe the typical needle used for infiltrations and ID blocks
A
ID block: 27 guage, 0.4mm diameter 34mm double bevelled stainless steel
Infiltration: 30 guage, 0.3mm 19mm double bevelled stiainless
15
Q
When do we use surface anaesthetic and what is it?
A
5% lidocain ointment
Not used routinely but used for childrens hospital
16
Q
What speed do we use for injecting LA?
A
2ml/20 seconds for ID block in loose tissue
1ml/15 seconds for infiltration in tighter tissue
17
Q
How do we know if anaesthetic has worked
A
wait a few minutes then question patient and test mucosa/drill dentine
18
Q
What are the common anaesthetics?
A
Lidocaine Articaine Mepivocaine Prilocaine buvidocaine
19
Q
When would we use articaine?
A
When we need a more potent anaesethetic (as it is 4%) such as anaesthetising adjacent teeth as the tooth in question is infected or mandibular infiltrations
20
Q
Why do anaesethics have adrenaline?
A
- To act as a vasoconstricter to prevent the anaesethic being taken away to increase the time of numbness
- reduce bleeding
- act against the vasodilation properties of anaesthetic agents
21
Q
Why might a patient require lidocaine/articaine plain? What is it?
A
Plain = no adrenaline
This is used when the patient has heart problems like hypertension or arrythmia
22
Q
What are the half lives of articaine or lidocaine
A
Lidocaine = 90 minute half life Articaine = 20 minute half life
23
Q
What anesthetic should we not use with pregnant patients?
A
Prilocaine as it has felypressin as its vasoconstrictor which is very similar in structure to vasopressin which causes uterine contractions.
Mupivacane causes maternal cardiac problems
24
Q
Which anaesthetic agent is short lasting? What is its onset, lasting time in pulp and soft tissue?
A
Mepivocaine 3% has an onset of 3-5 minutes with lasting time in the pulp of 20 - 40 mins and soft tissues 2-3 hours.
25
anaesethic can come with 1:50,000 and 1:100,000 epinephrine. What are the differences in effect?
No difference in onset, time or depth. Only difference is the higher concentration (1:50,000) leads to better haeostasis
26
What are the signs that La is working?
Blanching in the area, communication of 'numb' teeth and surroundings
27
What are the signs of toxicity/reactions to anesthetic?
confusion, auditory changes, tinnitus, dizziness, metallic taste
28
if a patient is allergic to anesthetic and we don't spot the sings, what can happen?
-seizures, respiratory arrest, coma
29
What is the longest lasting LA? When is it used?
Bupivocaine for long surgeries
30
What percentage NaOCl can students and post-grads use? what is its main function
1% and 5.25% - antimicrobial agent and dissolve residual pulp tissue and organic matter
31
What percant EDTA do we use and what is its main function
17% for smear layer removal
32
why do we rarely use iodine for irrigation
common allergen
33
when is anaesthetic useful?
reduce pain during surgery
reduce pain after surgery
localise pain
reduction of haemorrhage during surgery
34
where should we avoid during giving a maxillary infiltration?
floor of nose anteriorly - causes pain
| malar butress at 6's
35
after how long do we assume failure of anaesthetic infiltration?
6-8 minutes
36
How would we anaesthetise the upper 6 with infiltration? why is this different
apply LA to the 7 and 6 as the malar buttress is thick with no vascular channels
37
what anaesthetic blocks can we provide? what teeth do they numb
superior posterior regional block - upper 8-6
infra-orbital regional block - upper 1-5 and mesiobuccal cudp of 6
Inferior alveolar nerve block - lower 1-8
Mental nerve block 1-5
38
when do we use intrapapillary/intrligamentary injections and how are they done
paediatrics as palatine injections are too painful
haemophiliacs to avoid superior posterior dental blocks
needle perpendicular to long axis of tooth and occlusal plane in buccal papilla 2mm
after palate blanches, inject palatine nerve
39
when would we use intraosseous injections?
if supplementary anaesthesia is needed, e.g. irreversible pulpitits
40
what is an intraosseous injection
anaesthetic injected directly into the cancellous bone
| perpendicular to long axis of tooth
41
what is an analgesic
loss of pain
42
what is an anaesthetic
loss of sensation all together
43
what is the difference between general and local anaesthetic
GA looses consciousness and loss of sensation in whole body
| LA is localised sensation relief
44
what two main chemical classifications of anaesthetics are there? which are used more and why
esters and amide intermediate chain
| amides used more as esters are highly allergenic
45
what are the components of LA (5)
```
anaesthetic agent
vasoconstrictor
vehicle solution to dissolve
reducing agent to keep stable
fungicide
```
46
what are the three major parts of the anaesthetic agent?
weak base with the structure:
1. Aromatic (lipophilic dissolves in the lipid around the nerves to access the nerve itself) linked to an
2. intermediate chain (links terminals - used to be esters but found as allergens so now amides are used.)
3. with polar amino terminal (soluble in water so it can transfer in the interstitial fluids). Lidocaine has this general formula.
47
what are anaesthetic agents
weak organic bases that act on nerves to depress transmission of action potentials
48
why do anaesthetic agents have a non-polar organic and amid polar part?
Allows them to form an equilibrium of charged and non-charged particles
The LA is non-charged to travel over the epineurium, perineurium and endoneurium and then re-equilibrates its charged and non-charged ions and the charged ions bind the receptors and block Na channels
Lipophilic end alterns the membranes of the ion channels and blocks them.
49
are LA's soluble in water? why? what do we do about this?
weakly soluble in water
because of non-polar aromatic part
dispensed in salts to make more soluble
50
name four amide and two ester LAs
```
amide:
lidocaine
articaine
mupivocaine
prilocaine
bupivocaine
```
ester:
procaine
benzocaine
51
why is lidocaine more affective than procaine?
lidocaine has 25% non-ionised state so transfers across membrane
procaine has ~5% non-ionised state so less transfers across
52
why is anaesthetic less affective in infected areas?
infected areas are more acidic
acidic environments alter equilibrium of ionised and non-ionised anaesthetic
moves equilibrium to more ionised
less anaesthetic crosses the membrane
Increased vascularity means anaesthetic lasts in the area less time
53
what components of LA affect vasoconstriction
anaesthetic agent blocks sympathetic vasoconstriction causing vasodilation
adrenaline acts as a strong vasoconstrictor
54
which nerve fibres does anaesthetic act on (first?)
small pain nerve fibres first
| sensory and motor fibres after time
55
what is the half life of articaine and lidocaine?
articaine 20 mintues
| lidocaine 90 minutes
56
how are esters and amides metabolised? what problems should we be aware of
esters metabolised by esterase's in blood --> urine.
1 in 2800 lack enzymes for this and cannot have esters
amides metabolised in liver --> oxidised --> urine
liver disease patients will have slower metabolism
57
what are some characteristics of ideal anaesthetic
```
anaesthetise nerves without damage
non-toxic
easy to administer
short half life
no allergern
non-addictive (cocaine)
```
58
what is the long lasting amide anaesthetic
bupivocaine
59
in america noradrenaline is used as a vasoconstrictor, why is this not used in the UK
increased BP much more than adrenaline so can cause strokes
60
what affects does fellypressin have
mimics vasopressin and initiates uterine contractions if pregnant sending pregnant women into labour
coronary vasoconstriction so avoid with heart problems
61
how does adrenaline affect the body
acts on beta 1 receptors on the heart (beta 2 is lungs) increasing HR
acts on alpha 1 receptors causing vasoconstriction of blod vessels increasing BP
62
what is the toxic dose (of lidocaine and lidocaine plain)
maximum does safe to give to a patient
lidocaine : 7mg/kg
lidocaine plain: 4.4.mg/kg
63
what is the maximum does for a 70kg man of lidocaine without adrenaline?
lidocaine 2%
cartriage 2.2ml = 2.2g of solution
2.2g = 2200mg solution
2% of 2200 = 44mg lidocaine in 1 cartridge
weight = 70kg
maximum dose = 4.4mg/kg (7mg/kg with adrenaline)
70 x 4.4 = 308mg
308 / 44 = 7 cartridges
64
when do we use prilocaine over lidocaine and when do we avoid prilocaine
- lidocaine has adrenaline acts on HR bad for patients with heart problems/arrythmia
- prilocaine has felypressin as vasoconstrictor with less effect on heart
- avoid felypressin if pregnant as mimics vasopressin causing urterine contractions
65
if anaesthetic cartriage is brown what has happened
solution has oxidised - do not use
66
what do reducing agents do in anaesthetic
prevent oxidation of solution turning it brown
67
if LA is cloudy what is wrong
presence of fungi
loss of fungicide
do not use
68
what do statins do
inhibit HMG-CoA reductase
| involved in synthetic conversion of Acetyl-CoA into cholesterol
69
why are prilocaine 4% and articaine 4% not used as ID blcoks
too strong/potent and can have very long lasting effects on nerve action if they hit the nerve
70
where is a needle most likely to break
hub junction
71
what do we do in case of needle snap
try remove immediately with artery forceps
if not, refer to oral surgery immediately under GA
write in notes
72
where is the most likely place for haematoma to occur after injection and why
posterior superior alveolar block due to pterygoid plexus
73
what can an ID block haematoma lead to
trismus if in medial pterygoid- locked jaw
bruising
Swelling near airway
infection leading to severe trismus
74
what non-immediate problems can occur after anaesthetic and how can we avoid this
self trauma e.g. biting soft tissues, burns on mouth
| give pt advise not to eat anything hot or cold for 2 hours
75
what allergens are involved in giving anaesthetic (3)
anaesthetic injection (esters are much more allergenic than amides)
preventives but used less now
latex can be found in cartraiges
76
what should we do if we suspect an allergy to LA
send for sensitivity test at the dermatology department
positive allergy = use a different LA
negative = do infiltration with emergency kit by adrenaline and antihistamine
77
what are the toxic level effects of LA agent
low doses excite the CNs - normal dose
high doses depress CNS and heart function
prilocaine reduces RBC oxygen carrying capacity
78
how do we prevent toxic dose being given (3)
calculate maximum dose based on weight
inject slowly and look for reactions
aspirate before injection
79
what affect do anti-parkinsons drugs have on anaesthetic
reduce adrenaline rate of metabolism so reduce maximum dose by 50%
80
what do we do if we are unsure if a drug interacts with adrenaline and what is generally the case
look in the BSP guidelines to see interactions with the drug
| most cases, limit to 2 cartridges or use plain anaesthetic
81
what considerations should be taken with pregnant women and anaesthetic
should be avoiding dental procedures
Bupivacaine should be avoided as it causes more maternal cardiac problems and foetal hypoxia in animal models
Felypressin theoretically could lead to uterine contraction and a decrease in placental blood flow
Prilocaine crosses placental barrier more readily than lidocaine
Lidocaine and Adrenaline are the LA of choice
82
when should we use esters over amide
liver disease when taking beta blockers
83
if the mandible has been irradiated or had reduced vascularity for another reason, how does this affect our choice of anaesthetic
we should avoid further vasoconstriction to prevent necrosis so use plain lidocaine or plain anaesthetic
Maybe use stronger more potent articaine
84
if patient is at risk of endocarditis how does this effect anaesthetic
avoid intraligamentary injections to avoid bacteraemia
85
what are some circumstances where we throw away a cartraige
large head bubble - contaminated
out of date
cloudy - fungicide
brown -
86
how should we store LA
at room temperature 0-25 dgerees
do not freeze
bring to room temp before applying
87
if storing adrenaline LA how does this affect our storage of LA
do not store in day light
88
what is Amlodipine, what problem does it cause and how can we fix it
calcium ion channel blocker for high blood pressure
causes gingival enlargement NOT gingival hyperplasia
only resolution is to change medication, surgery only leads to recurrence
89
someone has a paracetamol overdose. What will happen to their PT or APTT
paracetamol overdose leads to liver failure
liver produces factors in intrinsic and extrinsic pathways
increases PT and APTT
90
what coagulation factors does warfarin act on and why
factors II, VII, IX and X (common and extrinsic)
all of the vitamin K dependant factors
warfarin inhibits Vitamin K Epoxide reductase which reduces vitamin K epoxide back to vitamin K
91
what does warfarin do
inhibits vitamin K epoxide reductase which stops replenishment of vitamin K
vitamin K needed for activation of clotting factors II, VII, IX and X of intrinsic and common coagulation pathways
prevents this, thins blood
92
if someone is on warfarin and we need to thicken their blood in an emergency, what do we do and why
give them vitamin 2-10mg
reduces the need for vitamin K epoxide reductase
replenishes vitamin K to activate factors II, VII, IX and X of extrinsic and common pathways
93
what does aspirin do
completely inactivates COX 1 2 3
COX 1 2 3 are responsible for causing the release of thromboxane and prostaglandins
thromboxane causes platelet aggregation
prostaglandins act on pain receptors
aspirin therefor reduces pain and blood clotting
94
how long are the lasts of aspirin and why
7 days
| lifespan of platelets as this is irreversible action on their COX complex
95
what are NOACs
oral anti-coagulants
act on final common coagulation pathway
thin blood
96
what is DDAVP, when is it given and what is its function
desmopressin, synthetic vasopressin, synthetic ADH
released endothelial stores of factor VIII
increases blood clotting via intrinsic pathway
97
if a patient is on NOACs (edoxoban) how does this affect how we do extractions
if more than three to be taken out, remove from medication
| avoid morning dose then take dose 4h after extraction
98
what can painkillers act as
anti-inflammatory
analgesic
anaesthetic
CNS depressers
99
why could we use anaesthetic at bleeding extraction sites
to stop bleeding
| adrenaline is a vasoconstrictor
100
what is the arachnoid pathway
Phospohlipid-->arachidonic acid --> prostaglandins + thromboxane + leukotrienes
pathway to produce inflammatory mediators such as leukotrienes (release of cytokines) , thromboxane (platlete function) and prostoglandins (pain)
101
how do analgesics like ibuprofen and aspirin act against pain and what are the side effects
inhibit COX-1 and COX-2 which catalyse the conversion of arachidic acid to prostaglandins which act on pain receptors to cause pain
also anti-inflammatory
gastric ulcers main side effect
102
what are 5 effects of COX inhibitors
```
reduced inflammation
reduced pain
decreased temperature
thinner blood
increased stomach acidity
```
103
what medication must we take with most NSAIDs and why
secondary drug to protect the GI tract from acid as NSAIDs act on COX complex which catalyses conversion of arachidic acid to prostaglandins. Prostaglandins reduce gastric acidity.
104
what are arthritis patients likely to be on and why
NSAIDs for joint pain releif
105
what are 3 common NSAIDs
ibuprofen
aspirin
diclofenac
106
what is diclofenac
NSAID
107
what is NNT and what is a NNT = 1 and NNT =2
number needed to treat (for medications)
NNT 1 = everyone gets pain reduction by 50%
NNT = half of population get pain reduction by 50%
108
what is BNF and how does it help
British national formulae
we can use it to look at interactions between drugs
dosage, how often and age restrictions of drugs
109
why can pregnant women not have most drugs, especially codeine. what pain killer can they have
most drugs especially codeine cross placental barrier into babies blood, paracetamol doesn't so is deemed safe.
if we dont follow this it can lead to congenital deformations (1st trimester) or growth problems (2n trimester)
110
if a patient has liver/kidney disease what should we do if prescribing
avoid prescribing any drugs due to poor metabolism of drugs
| consult GMP and pharmacist
111
what affects do NSAIDs have in pregnancy
haemorrage, closure of ductus arteriosus, pulmonary hypertension of newborn, delayed labour, increased duration of labour and increased blood loss in labour.
112
can NSAIDs be taken whilst breast feeding
deemed safe as amounts in breast milk are very minimal
| aspirin can cause blood clotting problems if with low vitamin K so avoid this
113
what doses do we give children - general conversion of adult dose
1st month up to a year = ⅛ adult dose
1-5 years = ¼ adult dose
6-12 years = ½ adult dose
114
what dosages go with paracetamol
500mg-1g 4 x 6hours max 4g in 24 hours
115
what does paracetamol act as
analgesic
antipyretic
not anti-inflammatory
116
what dosages for ibuprofen and how does it act and what is its maximum daily amount
NSAID - analgesic and antipyertic
| 200mg-400mg TDS. No more than 2.4g in any 24 hours
117
who shouldn't take ibuprofen
asthmatics, kidenys and pregnancy
118
what is diclofenac, where do we get it, what dosage do we give and who cannot have it
analgesic/anti-infammatory/NSAID/antipyretic
not OTC must get prescription
bad interactions with asthmatics and high allergern
75-150mg TDS
119
why do NSAIDs cause problems with asthmatics
NSAIDs reduce prostaglandin production
prostaglandins control smooth muscle action
asthma is swollen bronchiole tubes and changing prostaglandin levels can alter bronchioles
Ibuprofen, aspirin and diclofenac
120
what age is aspirin allowed for use and why
above the age of 16
| below this age- risk of reyes syndrome
121
what drug can cause Reyes syndrome
aspirin under age of 16
122
when should we not recommend NSAIDs (6)
```
history of stomach ulcers/bleeds
pregnancy
allergy to NSAIDs
asthma
on warfarin
if already on an NSAID
```
123
when are opioids used for pain relief and are they used in dentistry
severe moderate pain - act on CNS
if NSAIDs are contra-indicated/on NSAIDs already
not used in dentistry
124
how much is the NHS prescription fee and if a drug we are recommending is available OTC what should we do
£8.20
| tell them to buy it OTC
125
what painkillers should we (not) recommend
not aspirin if bleeding as this thins blood (extraction)
| ibuprofen good but not asthmatics
126
what is paracetamol and how does it work and compare to NSAIDS
```
not an NSAID
antipyretic
analgesic
not anti-inflammatory
blocks prostaglandin production
-doesnt antiinflammatory, very weakly blocks COX enzymes, doesn't cross placental border
```
127
when is paracetamol recommended
if allergic or contra-indicated NSAIDS
not if liver failure/alcoholic
Pregnancy- doesn't affect baby
tootheache or headache or fever
128
table of analgesics
x NSAID analgesic anti-inflammatory anti-pyretic
paracetamol tick tick
aspirin tick tick tick tick
ibuprofen tick tick tick tick
diclofenac tick tick tick tick
codeine tick tick
129
how is the BNF laid out
```
by medication class e.g. epilepsy, heart failure etc.
in back we find index
further back interactions of different drugs
```
130
what can we prescribe in private, NHS and hospital dentistry
private - anything
NHS - anything in the DPF dental practitioner formulae (dental preperations)
hostpital - anything
131
when would a dentistry prescribe codeine
after trying ibuprofen and paracetamol
132
how are medicines classified
OTC over the counter or GSL general sales list
pharmacy only e.g. cocodamol 8/500
prescription only e.g. cocodamol 30/500 or amoxicillin
by their schedule
133
what are the drug schedules
Schedule 1 – No medicinal use e.g. ecstasy, LSD
Schedule 2 – Subject to full controlled requirements, but have medicinal use e.g. cocaine (vasoconstrictor) e.g. heroin (diamorphine – given for MI)
Schedule 3 – subject to written requirements, but not safe, custody requirements or keep registers – just invoices for 2 yrs e.g. midazolam, temazepam
Schedule 4 – Benzodiazepines other than midaz/temaz and also Z-drugs - no CD requirements
Schedule 5 – Due to strength, are exempt from CD requirements – e.g. Oramorph
134
what is midazolam and what schedule drug is it
schedule 3 due to strength
| used for sedation purposes
135
what is cocodamol, when is it used and what are the side effects. dosage
mixture of paracetamol and codeine opioid
constipation
500mg/8mg short course
136
what dose of cocodamol can we use
1-2 tablets TDS (max 8/day) either
Co Codamol 8//500 - only OTC preparation
Co Codamol 15/500
Co Codamol 30/500
137
what three strengths of co-codamol do we have and which are available OTC
Co Codamol 8//500 - only OTC preparation
Co Codamol 15/500
Co Codamol 30/500
138
compare aspirin to paracetamol
aspirin irreversible inhibits COX1 and COX2 whereas paracetamol weakly inhibits COX2
aspirin causes gastric ulcers over time whereas paracetamol doesnt
aspirin is an NSAID but paracetamol is not
Both antiinflammatories and antipyretic
139
what are the benefits of paracetamol over NSAIDs
can be used if NSAID contraindicated
| do not affect GI tract so does not cause gastric ulcers
140
what must be on an NHS prescription
pt details : name, DOB, adress
drug details : type, route e.g. oral, dose, how many times a day, how long
sign and print name of consultant with date
stamp with printed name of practice
141
what does this mean on a prescription: PO
per orum - oral
142
what is the difference between an NHS or private prescription
private must include GDC code so pharmacy can track and confirm registration, NHS must have a stamp of the hospital
143
what does this mean on a prescription: PV
vaginally
144
what does this mean on a prescription: PR
rectum
145
what does this mean on a prescription: IV
intravenous
146
what does this mean on a prescription: IM
intramuscular
147
what does this mean on a prescription: SC
sub cutaneous
148
what does this mean on a prescription: top
topical
149
what does this mean on a prescription: M/W
mouthwash
150
what does this mean on a prescription: PRN
take when required, no pain = no take
151
what does this mean on a prescription: stat
immediately
152
what does this mean on a prescription: QDS
4 times daily
153
what does this mean on a prescription: TDS
3 times daily
154
what does this mean on a prescription: BD
twice a day
155
what does this mean on a prescription: nocte
night
156
what does this mean on a prescription: QHS
every night before bed
157
if there are severe adverse reactions to a drug marked with a black traingle in the BNF, what do we do
immediately notify the MHRA - medical and healthcare products regulatory advisory
Report all serious patient incidents to the National Reporting and Learning System if such incidents are not automatically reported where you work
Inform the patient’s general practitioner, the pharmacy that supplied the medicine, the local controlled drugs accountable officer and the medicines manufacturer
158
what is MHRA
medical and healthcare products regulatory advisory
| advise if adverse reaction to a medicine
159
what are some ester anaesthetics
procaine and mupivacaine
160
what is the implication of giving a haemophiliac a ID block
haemorrhage and bleeding
| swelling that can possibly block airway
161
how long is the half life, pulpal anaesthesia and soft tissue anaesthesia of lidocaine
Half life 90 minutes
pulpal anaesthesia 45mins
soft tissue anaesthesia 2-3hours
162
how long is the half life, pulpal anaesthesia and soft tissue anaesthesia of articaine
20 minute half life
pulpal anaesthesia 45mins
soft tissue anaesthesia 2-3hours
163
why is aspiration especially important for articaine
intravenous injections of articaine can lead to convulsions (epileptic fits)
164
what percentages do we use of lidocaine, lidocaine plain, procaine, procaine plain, articaine
```
lidocaine 2%
lidocaine plain 4%
procaine 3%
procaine plain 4%
articaine 4%
```
165
what are the maximum doses for articaine (and for articaine for children), lidocaine and lidocaine plain
articaine = 7mg/kg (for children 5mg/kg)
lidocaine plain = 4.4mg/kg
lidocaine = 7mg/kg
166
how do we estimate a child's weight
(age + 4) x 2
167
what is the average weight of an adult
70kg
168
what are some advantages and disadvantages of ultra-safety plus
single use - sterile (more waste, less sterilization)
needle sheath
auto-aspirator
no recapping neccessary
169
how can we reduce anxiety for a child having a needle
show them the needle, explain that it is sleepy juice for the tooth
don't let them see it going in
explain every step
distract them
170
if a child is extremely anxious, what options do we have for operative procedures
systematic desensitisation
| sedation
171
what alterations to oral anaesthetic occur in children
always use topical anaesthetic 5% lidocaine ointment 2-5 minute onset
weaker, thinner more porous bone so infiltrations can be used for all teeth in young
mandibular foramen is lower and more distal so aim lower down for ID block
172
when do we provide intrapapillary injections
in children for palatal anaesthetic as palatal injections are too painful
173
explain how to numb the palatal aspect of a child's upper teeth
topical anaesthetic 5% lidocaine ointment on buccal side and palatal side
intrapapillary injection:
- inject at into the papilla parallel to occlusal plane and perpendicular to long axis of tooth 1-2 mm and inject slowly
- repeat at adjacent papilla until palatal blanching meets
- papillary injection
174
how do we change ID blocks for children
instead of coming from premolar region, come from first molar region as more distal
aim more down as mandibular foramen is lower
175
when do we provide no ID block, altered child ID block and adult ID block
no ID block before age of 6
6-9 altered ID block
9+ use adult
176
what is the rule of 10 for children's pulpal anaesthesia and when do we change the number and why
Age + How many teeth away from the midline < 10 = just infiltration
Age + How many teeth away from midline >10 = ID block
rule of 12 for articaine as it is more potent and soluble
177
if a seven year old needed pulpal anaesthesia with lidocaine on their lower right 4, what injection would we do and why? would it change if it was with articaine?
```
4 + 7 = 11
rule of 10 for lidociane
11 > 10 therefore provide ID block
with articaine we use rule of 12
11<12 therefore infiltration
```
178
what do we do if an ID block fails and why is this a last port of call
intraligamentary injection into the periodontium
| higher risk of bacteraemia and can affect developing teeth
179
what is anaesthetised during intraligamentary injection
immediate pulpal anaesthesia
| not tongue, lip or gingiva
180
how do we do an intraligamentary injection
```
using peripress (stronger system)
50-60 degrees to occlusal plane
interproximal space
advance needle until bony resistance
0.4-0.6ml mesial and repeat distally
```
181
what angle of injection do we use for intraligamentary injections
50-60 degrees to occlusal plane
182
what is the 'wand' and when do we use it
```
computer controlled anaesthetic delivery
for anxious children
less intimidating
slow delivery
good for palatal
```
183
what drugs cause MRONJ
bisphosphonates
Monoclonal antibodies - e.g. Denosumab
Tyrosine Kinase inhibitors - e.g. Sunitinib are all small cell receptor antagonists
184
what increases risk of MRONJ with bisphosphonates
steroids or IV
185
what are bisphosphonates
drugs reduce bone turnover by altering osteoclasts to treat some cancers, osteoporosis and pagets disease
186
what is the structure of bisphosphonates
a central carbon
2 phosphonate groups PO3
2 variable R groups
R groups can be N (nitrogen) containing or non-N containing
187
what are the implications of the different R groups on bisphosphonates and how do they work
can be N or non-N containing R groups
N = Prevents formation of proteins needed to maintain osteoclast cytoskeleton (loss of ruffle border which is the surface used for breaking down bone) Most clinically important ones: alendronate, risedronate, pamidronate, etc.
non-N = Compete with ATP leading to osteoclast apoptosis - Too toxic to be used clinically usually as they kill off osteoclasts
188
what are the 2 main circumstances we use bisphosphonates and what is there risk of developing MRONJ
metastatic breast cancer - IV medication high dose 10% risk of MRONJ
osteoporosis - low dose 1/100,000 , 1/1000 after extraction
risk increased with steroids
189
how does MRONJ occur because of bisphosphonates (3)
bisphosphonates:
- act as anti-angiogenesis so reduce blod flow to bone
- can kill/reduce action of bone cells
- toxic to overlying soft tissues so prevent healing over
190
what is a drug holiday
how long a drug is stopped useage
191
what drug holidays benefit MRONJ reduced risk
bisphosphonate 12m reduces risk
| 3m has some merit
192
what must we consider when considering a drug holiday
do the pros of stopping the medication outweigh the risks involved with keeping the drug on
193
for MRONJ high risk patients, what will antibiotics do?
not reduce incidence but reduce severity
194
what dosage of ibuprofen can we advise
200-400mg TDS
195
what dosage diclofenac can we advise
25-50mg TDS
196
what dose aspirin can we advise
300-900mg 4DS - not for asthmatics, bloodthinner
197
what must IRN be for single and multiple extractions
single: <4 in last 72 hours
multiple: <3.5 in last 72 hours
198
what allergern is found in fluoride varnish that cannot be given to asthmatics and what is an alternative
colophony in duraphat - use flourimax
199
what ppm of flouride is in flouride varnish
22,600 ppm F-
200
what is xylitol
stops metabolism of strep. Mutans - major carious bacteria
found in sugar free chewing gum
natural sweetner
201
what is Riva Star
Silver Diamine flouride rubbed on carious lesions to arrest and turn black
202
what separates aspirin from other NSAIDs
it irreversibly blocks COX I and COX II
others only reversibly block
more potent and last longer
203
what organ (system) are aspirin and ibuprofen likely to act on
```
aspirin = GI tract stomach ulcers
ibuprofen = kidneys
```
204
if a drug is anti-pyretic, where does it act
hypothalamus
| temperature control
205
what are corticosteroids
produced in the cortex of adrenal gland
steroids - 4 ring steroid skeleton
all end in 'one' and are analgesics and anti-inflammatory
206
how do steroids work compared to NSAIDs
steroids inhibit phospholipase A2 which catalyses conversion of phospholipids to arachidonic acid (therefore preventing production of prostaglandins)
NSAIDs inhibit COX1/2 preventing catalysation of arachidonic acid to prostoglandins
207
what are some side effects of corticosteroids
```
immunosupressant
redistribution of body fat
acute adrenal insufficency
osteoperosis
gastric ulcers
hyperglaecaemia
```
208
where are etser LAs and amide LAs metabolised
esters in blood plasma
| amides in liver
209
which LA is safest and least safe for children
lidocaine most safe
| mupivocaine least safe
210
why is articaine metabolised faster than other anaesthetics
articaine is mainly amide but has 1 ester chain
| metabolised in the liver AND blood plasma
211
why can mepivacaine be used without adrenaline successfully
mepivacaine causes least amount of vasodilation
212
what are the functions of a vasoconstrictor inLA (4)
promote haemostasis
reduce toxicity
prolong numbness
counteract vasodilation
all because they slow blood flow
213
What drugs are commonly causing gingival hyperplasia
Cyclosporine- immunosupressant, crohns
Phenytoin - anti-convulsant, epilepsy
Amlodipine - beta channel blocker, high BP
214
give three things we avoid giving to patients with an aspirin allergy
aspirin analgesic
bongela = derivatives of salicylic acid
CaOH base = salicylate ester component
215
give 2 reason polypharmacy might cause dental problems
sugar containing medications increase caries risk
| xerostomia
216
what is herparin
anticoagulant
217
what affects do steroids have on haemostasis
make skin thinner causing bruising and bleeding
218
how do we treat venous and arteriole thrombosis
```
arterial = antiplatelet = aspirin, clopidogrel
venous = anticoagulant = herparin, LMWH, warfarin, edoxaban
```
219
what are 2 antiplatelet drug
aspirin
| clopidogrel
220
what are some anticoagulants and how are they applied (3)
warfarin- PO
herparin - IV
low molecular weight heparin LMWH - SC
221
what are DOACs
direct oral anti-coagulants e.g. edoxaban, rivaroxaban
222
how does heparin work and how do we apply it and why
acts on anti-thrombin increasing activity
decreases fibrin so decreases platelet plug strength
give SC or IV as not absorbed in gut
223
compare herparin and warfarin
heparin =
- given IC or IV as not absorbed by gut
- acts on anti-thrombin reducing coagulation cascade
- acts on common pathway
warfarin =
- vitamin K antagonist
- prevents production of factors II, VII, IX and X
- acts on coagulation cascade
- given orally
- acts on intrinsic, common and extrinsic pathwyas
224
how long does it take warfarin to start and stop
3-4 days to start
| 4-5 days to stop
225
what determines the patients warfarin dose
stability of patients INR
226
what is the target INR for a pt with recent DVT or PE
2/3
227
why are DOACs better than warfarin
```
less affect
quicker time on and time off
predictable affect on coagulation
no regular blood monitoring
no effects with food or alcohol
very few interactions with drugs
short half life 10-15 hours
```
228
what is the half life of a DOAC
~10-15 hours
229
what are the dis-advtanges of warfarin
slow time on and time off
heavy bleeding e.g. nose bleeds, worse menstrual bleeding, bruising
interactions with other drugs and alcohol
avoid vitamin K e.g. leafy greens
not predicatable how it will affect warfarin
regular blood monitoring needed
230
how do most DOACs work
act on common coagulation pathway (most on factor X)
231
disadvantages of DOACs (2)
```
renally exerted (not with kidney disease)
no direct antidote for reversal
```
232
when can we not use DOACs over warfarin
triple positive APLs - antiplatelet syndrome
heart valve replacement
increased incidence of stroke/MI with DOACs
233
how do we treat iron deficiency
TREAT UNDERLYING CAUSE
200mg ferrous sulphate daily (not TDS like BSP says)
until Hb count back to normal and further 3 months o build up stores
234
how much vitamin B12 do we give if they cannot absorb (malabsorption, loss of part of GI tract)
1mg IM every 2 days until Hb back to normal
| 1mg IM every 3 months lifelong
235
do we provide folate or b12 first if deficient in both
b12
236
how do we treat folate deficency
oral folate 5mg a day
| for all causes
237
which 3 anaesthetics do we avoid during pregnancy
prilocaine crosses placental blood barrier
procaine involves felypression --> uterine contractions
mepivacaine causes material cardiac problems
238
What 3 senarios do we never interuppt anticoagulant/antiplatelet action
Patients with stents or metal heart valves
Patients who have had a Pulmanory embolism or DVT in past 3 months
Patients on therapy for cardioversion
239
What is a rare side effect of prilocaine? What effects does it have
Methaemaglobinaemia
| Causing shortness of breath, cyanosis (going blue) and headaches
240
What is the best analgesic for neuralgic pain
Carbamazepine
