Prescribing In Oral Medicine

Question 1

What is an Ace inhibitor

Answer 1

Drug used in the treatment ofhigh blood pressureandheart failure.

Angiotensin-converting-enzyme inhibitor

Usually ends in pril Eg ramipril

Question 2

What are the medical uses of ace inhibitors

Answer 2

ACE inhibitors were initially approved for the treatment of hypertension and can be used alone or in combination with other anti-hypertensive medications. Later, they were found useful for other cardiovascular and kidney diseases[1]including:

Acutemyocardial infarction(heart attack)

Heart failure(left ventricular systolic dysfunction)

Kidney complications ofdiabetes mellitus(diabetic nephropathy)

In treating high blood pressure, ACE inhibitors are often the first drug choice, particularly when diabetes is present,[2]but age can lead to different choices and it is common to need more than one drug to obtain the desired improvement. There are fixed-dosecombination drugs, such asACE inhibitor and thiazide combinations. ACE inhibitors have also been used inchronic kidney failureand kidney involvement insystemic sclerosis(hardening of tissues, as scleroderma renal crisis). In those with stable coronary artery disease, but no heart failure, benefits are similar to other usual treatments.[3]

In 2012, there was ameta-analysispublished in theBMJthat described the protective role of ACE inhibitors in reducing the risk of pneumonia when compared toARBs. The authors found a decreased risk in patients with previous stroke (54% risk reduction), with heart failure (37% risk reduction), and of Asian descent (43% risk reduction vs 54% risk reduction in non-Asian population). However, no reduced pneumonia related mortality was observed.[4]

OtherEdit

ACE inhibitors may also be used to help decrease excessive water consumption in people withschizophreniaresulting inpsychogenic polydipsia.[5][6]A double-blind, placebo-controlled trial showed that when used for this purpose,enalaprilled to decreased consumption (determined by urine output and osmality) in 60% of people;[7]the same effect has been demonstrated in other ACE inhibitors

Question 3

What does the dental practitioners formulary include

Answer 3

You are viewing BNF. If you require BNF for Children, useBNFC.

Prescribing in dental practice

General guidance

Advice on the drug management of dental and oral conditions has been integrated into the main text. For ease of access, guidance on such conditions is usually identified by means of a relevant heading (e.g. Dental and Orofacial Pain) in the appropriate sections of the BNF.

The following is a list of topics of particular relevance to dentists.

Prescribing by dentists, seePrescription writing

Oral side-effects of drugs, seeAdverse reactions to drugs

Medical emergencies in dental practice, see below

Medical problems in dental practice, see below

Drug management of dental and oral conditions

Dental and orofacial pain

Neuropathic pain

Non-opioid analgesics and compound analgesic preparations, seeAnalgesics

Opioid analgesics, seeAnalgesics

Non-steroidal anti-inflammatory drugs

Oral infections

Bacterial infections, seeAntibacterials, principles of therapy

Phenoxymethylpenicillin

Broad-spectrum penicillins (amoxicillinandampicillin)

Cephalosporins (cefalexinandcefradine)

Tetracyclines

Macrolides (clarithromycin,erythromycinandazithromycin)

Clindamycin

Metronidazole

Fusidic acid

Fungal infections, seeAntifungals, systemic use

Local treatment, seeOropharyngeal fungal infections

Systemic treatment, seeAntifungals, systemic use

Viral infections

Herpetic gingivostomatitis, local treatment, seeOropharyngeal viral infections

Herpetic gingivostomatitis, systemic treatment, seeOropharyngeal viral infectionsandHerpesvirus infections

Herpes labialis, seeSkin infections

Anaesthetics, anxiolytics and hypnotics

Sedation, anaesthesia, and resuscitation in dental practice

Hypnotics, seeHypnotics and anxiolytics

Sedation for dental procedures, seeHypnotics and anxiolytics

Anaesthesia (local)

Minerals

Fluoride imbalance

Oral ulceration and inflammation

Mouthwashes, gargles and dentifrices, seeMouthwashes and other preparations for oropharyngeal use

Dry mouth, seeTreatment of dry mouth

Aromatic inhalations, seeAromatic inhalations, cough preparations and systemic nasal decongestants

Nasal decongestants, seeAromatic inhalations, cough preparations and systemic nasal decongestants

Question 4

What drugs are used in the management of med emergencies in dental practice

Answer 4

Adrenaline/epinephrineInjection, adrenaline 1 in 1000, (adrenaline 1 mg/mL as acid tartrate), 1 mL amps

AspirinDispersible Tablets 300 mg

GlucagonInjection,glucagon(as hydrochloride), 1- unit vial (with solvent)

Glucose(for administration by mouth)

Glyceryl trinitrateSpray

MidazolamOromucosal Solution

Oxygen

SalbutamolAerosol Inhalation,salbutamol100 micrograms/ metered inhalation

Question 5

How should adrenal insufficiency be managed in the dental practice

Answer 5

Adrenal insufficiency may follow prolonged therapy with corticosteroids and can persist for years after stopping. A patient with adrenal insufficiency may become hypotensive under the stress of a dental visit (important: see individual monographs for details of corticosteroid cover before dental surgical procedures under general anaesthesia).

Management

Lay the patient flat

Giveoxygen

Transfer patient urgently to hospital

Question 6

In the UK what law governs prescribing

Answer 6

Medicines act 1968

Question 7

What are signs and symptoms of anaphylaxis

Answer 7

Symptoms and signs

Paraesthesia, flushing, and swelling of face

Generalised itching, especially of hands and feet

Bronchospasm and laryngospasm (with wheezing and difficulty in breathing)

Rapid weak pulse together with fall in blood pressure and pallor; finally cardiac arrest

Question 8

What is anaphylaxis

Answer 8

A severe allergic reaction may follow oral or parenteral administration of a drug. Anaphylactic reactions in dentistry may follow the administration of a drug or contact with substances such as latex in surgical gloves. In general, the more rapid the onset of the reaction the more profound it tends to be. Symptoms may develop within minutes and rapid treatment is essential.

Anaphylactic reactions may also be associated withadditivesandexcipientsin foods and medicines. Refined arachis (peanut) oil, which may be present in some medicinal products, is unlikely to cause an allergic reaction—nevertheless it is wise to check the full formula of preparations which may contain allergens (including those for topical application, particularly if they are intended for use in the mouth or for application to the nasal mucosa).

Question 9

How is anaphylaxis managed

Answer 9

First-line treatment includes securing the airway, restoration of blood pressure (laying the patient flat and raising the feet, or in the recovery position if unconscious or nauseous and at risk of vomiting), and administration ofadrenaline/epinephrineinjection. This is givenintramuscularlyin a dose of 500 micrograms (0.5 mL adrenaline injection 1 in 1000); a dose of 300 micrograms (0.3 mL adrenaline injection 1 in 1000) may be appropriate for immediate self-administration. The dose is repeated if necessary at 5-minute intervals according to blood pressure, pulse, and respiratory function.Oxygenadministration is also of primary importance. Arrangements should be made to transfer the patient to hospital urgently.

Question 10

How is an asthma attack managed

Answer 10

Patients with asthma may have an attack while at the dental surgery. Most attacks will respond to 2 puffs of the patient’s short-acting beta2agonist inhaler such assalbutamol100 micrograms/puff; further puffs are required if the patient does not respond rapidly. If the patient is unable to use the inhaler effectively, further puffs should be given through a large-volume spacer device (or, if not available, through a plastic or paper cup with a hole in the bottom for the inhaler mouthpiece). If the response remains unsatisfactory, or if further deterioration occurs, then the patient should be transferred urgently to hospital. Whilst awaiting transfer,oxygenshould be given withsalbutamol5 mg orterbutaline sulfate10 mg by nebuliser; if a nebuliser is unavailable, then 2–10 puffs ofsalbutamol100 micrograms/metered inhalation should be given (preferably by a large-volume spacer), and repeated every 10–20 minutes if necessary. If asthma is part of a more generalised anaphylactic reaction, an intramuscular injection ofadrenaline/epinephrine(as detailed under Anaphylaxis) should be given.

Question 11

How is severe asthma managed

Answer 11

Patients with severe chronic asthma or whose asthma has deteriorated previously during a dental procedure may require an increase in their prophylactic medication before a dental procedure. This should be discussed with the patient’s medical practitioner and may include increasing the dose of inhaled or oral corticosteroid.

Question 12

What are the signs and symptoms of myocardial infarction

Answer 12

Symptoms and signs of myocardial infarction:

Progressive onset of severe, crushing pain across front of chest; pain may radiate towards the shoulder and down arm, or into neck and jaw

Skin becomes pale and clammy

Nausea and vomiting are common

Pulse may be weak and blood pressure may fall

Breathlessness

Question 13

What is the initial management of myocardial infarction

Answer 13

Initial management of myocardial infarction:

Call immediately for medical assistance and an ambulance, as appropriate.

Allow the patient to rest in the position that feels most comfortable; in the presence of breathlessness this is likely to be sitting position, whereas the syncopal patient should be laid flat; often an intermediate position (dictated by the patient) will be most appropriate.Oxygenmay be administered.

Sublingualglyceryl trinitratemay relieve pain. Intramuscular injection of drugs should be avoided because absorption may be too slow (particularly when cardiac output is reduced) and pain relief is inadequate. Intramuscular injection also increases the risk of local bleeding into the muscle if the patient is given a thrombolytic drug.

Reassure the patient as much as possible to relieve further anxiety. If available,aspirinin a single dose of 300 mg should be given. A note (to say that aspirin has been given) should be sent with the patient to the hospital. For further details on the initial management of myocardial infarction, see Management of ST-Segment Elevation Myocardial Infarction.

If the patient collapses and loses consciousness attempt standard resuscitation measures. See alsoalgorithmof the procedure forCardiopulmonary resuscitation.

Question 14

What should be remembered when treating a pt with epilepsy

Answer 14

Patients with epilepsy must continue with their normal dosage of anticonvulsant drugs when attending for dental treatment. It is not uncommon for epileptic patients not to volunteer the information that they are epileptic but there should be little difficulty in recognising a tonic-clonic (grand mal) seizure.

Question 15

What are the signs of symptoms of epilepsy

Answer 15

There may be a brief warning (but variable)

Sudden loss of consciousness, the patient becomes rigid, falls, may give a cry, and becomes cyanotic (tonic phase)

After 30 seconds, there are jerking movements of the limbs; the tongue may be bitten (clonic phase)

There may be frothing from mouth and urinary incontinence

The seizure typically lasts a few minutes; the patient may then become flaccid but remain unconscious. After a variable time the patient regains consciousness but may remain confused for a while

Question 16

How is epilepsy managed

Answer 16

During a convulsion try to ensure that the patient is not at risk from injury but make no attempt to put anything in the mouth or between the teeth (in mistaken belief that this will protect the tongue). Giveoxygento support respiration if necessary.

Do not attempt to restrain convulsive movements.

After convulsive movements have subsided place the patient in the coma (recovery) position and check the airway.

After the convulsion the patient may be confused (‘post-ictal confusion’) and may need reassurance and sympathy. The patient should not be sent home until fully recovered. Seek medical attention or transfer the patient to hospital if it was the first episode of epilepsy, or if the convulsion was atypical, prolonged (or repeated), or if injury occurred.

Medication should only be given if convulsive seizures are prolonged (convulsive movements lasting 5 minutes or longer) or repeated rapidly.

Midazolamoromucosal solution can be given by the buccal route in adults as a single dose of 10 mg [unlicensed]. For further details on the management of status epilepticus, including details of paediatric doses ofmidazolam, see Drugs used in status epilepticus (Epilepsy).

Focal seizures similarly need very little active management (in an automatism only a minimum amount of restraint should be applied to prevent injury). Again, the patient should be observed until post-ictal confusion has completely resolved.

Question 17

What are the signs and symptoms of hypoglycaemia

Answer 17

Symptoms and signs

Shaking and trembling

Sweating

‘Pins and needles’ in lips and tongue

Hunger

Palpitation

Headache (occasionally)

Double vision

Difficulty in concentration

Slurring of speech

Confusion

Change of behaviour; truculence

Convulsions

Unconsciousness

Question 18

How is hypoglycaemia treated in practice

Answer 18

Initially glucose 10–20 g is given by mouth either in liquid form or as granulated sugar or sugar lumps. Approximately 10 g of glucose is available from non-diet versions ofLucozade®Energy Original110 mL,Coca- Cola®100 mL,Ribena®Blackcurrant19 mL (to be diluted), 2 teaspoons sugar, and also from 3 sugar lumps. (Proprietary products of quick-acting carbohydrate (e.g.GlucoGel®,Dextrogel®,GSF-Syrup®,Rapilose®gel) are available on prescription for the patient to keep to hand in case of hypoglycaemia). If necessary this may be repeated in 10–15 minutes.

Note: the carbohydrate content of some commercially available glucose-containing drinks is currently subject to change—individual product labels should be checked. Patients should be aware that for a time, both old and new bottles and cans may be available—individual product labels should be checked.

If glucose cannot be given by mouth, if it is ineffective, or if the hypoglycaemia causes unconsciousness,glucagon1 mg (1 unit) should be given by intramuscular (or subcutaneous) injection; a child under 8 years or of body-weight under 25 kg should be given 500 micrograms. Once the patient regains consciousness oral glucose should be administered as above. If glucagon is ineffective or contra-indicated, the patient should be transferred urgently to hospital. The patient must also be admitted to hospital if hypoglycaemia is caused by an oral antidiabetic drug.

Question 19

What is syncope, its signs and symptoms, management and ddx

Answer 19

Insufficient blood supply to the brain results in loss of consciousness. The commonest cause is a vasovagal attack or simple faint (syncope) due to emotional stress.

Symptoms and signs

Patient feels faint

Low blood pressure

Pallor and sweating

Yawning and slow pulse

Nausea and vomiting

Dilated pupils

Muscular twitching

Management

Lay the patient as flat as is reasonably comfortable and, in the absence of associated breathlessness, raise the legs to improve cerebral circulation

Loosen any tight clothing around the neck

Once consciousness is regained, give sugar in water or a cup of sweet tea

Other possible causes

Postural hypotension can be a consequence of rising abruptly or of standing upright for too long; antihypertensive drugs predispose to this. When rising, susceptible patients should take their time. Management is as for a vasovagal attack.

Under stressful circumstances, some patients hyperventilate. This gives rise to feelings of faintness but does not usually result in syncope. In most cases reassurance is all that is necessary; rebreathing from cupped hands or a bag may be helpful but calls for careful supervision.

Adrenal insufficiency or arrhythmias are other possible causes of syncope.

Question 20

What is syncope

Answer 20

Insufficient blood supply to the brain results in loss of consciousness. The commonest cause is a vasovagal attack or simple faint (syncope) due to emotional stress.

Question 21

What are the signs and symptoms of syncope

Answer 21

Symptoms and signs

Patient feels faint

Low blood pressure

Pallor and sweating

Yawning and slow pulse

Nausea and vomiting

Dilated pupils

Muscular twitching

Question 22

What is the mx of syncope

Answer 22

Management

Lay the patient as flat as is reasonably comfortable and, in the absence of associated breathlessness, raise the legs to improve cerebral circulation

Loosen any tight clothing around the neck

Once consciousness is regained, give sugar in water or a cup of sweet tea

Question 23

What are other possible causes of syncope

Answer 23

Other possible causes

Postural hypotension can be a consequence of rising abruptly or of standing upright for too long; antihypertensive drugs predispose to this. When rising, susceptible patients should take their time. Management is as for a vasovagal attack.

Under stressful circumstances, some patients hyperventilate. This gives rise to feelings of faintness but does not usually result in syncope. In most cases reassurance is all that is necessary; rebreathing from cupped hands or a bag may be helpful but calls for careful supervision.

Adrenal insufficiency or arrhythmias are other possible causes of syncope.

Question 24

How should allergies be managed in the dental practice

Answer 24

Patients should be asked about any history of allergy; those with a history of atopic allergy (asthma, eczema, hay fever, etc.) are at special risk. Those with a history of a severe allergy or of anaphylactic reactions are at high risk—it is essential to confirm that they are not allergic to any medication, or to any dental materials or equipment (including latex gloves). See also Anaphylaxis above.

Question 25

How are arrhythmias managed in the dental practice

Answer 25

Patients, especially those who suffer from heart failure or who have sustained a myocardial infarction, may have irregular cardiac rhythm. Atrial fibrillation is a common arrhythmia even in patients with normal hearts and is of little concern except that dentists should be aware that such patients may be receiving anticoagulant therapy. The patient’s medical practitioner should be asked whether any special precautions are necessary. Premedication (e.g. withtemazepam) may be useful in some instances for very anxious patients.

Question 26

What are benzodiazepines

Answer 26

class of psychoactive drugs whose core chemical structure is the fusion of a benzene ring and a diazepine ring.

treatinganxiety,insomnia,agitation,seizures,muscle spasms,alcohol withdrawaland as apremedicationfor medical or dental procedures.[5]Benzodiazepines are categorized as either short, intermediary, or long-acting. Short- and intermediate-acting benzodiazepines are preferred for the treatment of insomnia; longer-acting benzodiazepines are recommended for the treatment of anxiety.

Question 27

If you suspect an adverse drug reaction what should you do?

Answer 27

Towards the back of the BNF are a number of copies of the Yellow Card which is prepared by the commission on human medicines CHM and should be used to report to the medicines and healthcare products regulatory agency MHRA

Question 28

What is the BNF

Answer 28

British national formulary isan independent professional publication that provides a comprehensive source of information on aspects of prescribing
Updated twice yearly

Question 29

How often is the BNF updated

Answer 29

Twice yearly

Question 30

What is the dpf

Answer 30

A separate section in the BNF lists those medicines that are approved for prescription by general dentists under NHS regulations

Question 31

What is the impact of renal impairment on prescribing

Answer 31

Possible toxicity due to reduced excretion of drug
Increased risk of Hypersensitivity
Increased risk of side effects
Reduced function of the drug

Question 32

Possible toxicity due to reduced excretion of drug
Increased risk of Hypersensitivity
Increased risk of side effects
Reduced function of the drug
Are all consequences of what bodily impairment

Answer 32

Renal

Question 33

What does liver disease have on prescribing

Answer 33

Impaired drug metabolism
Hypoproteinaemia increased toxocity of highly protein bound drugs
Reduced clotting
Fluid overload
Hepatotoxic drugs

Question 34

Impaired drug metabolism
Hypoproteinaemia increased toxocity of highly protein bound drugs
Reduced clotting
Fluid overload
Hepatotoxic drugs
Are all consequences of what impairment?

Answer 34

Liver disease

Question 35

What are the components of a prescription?

Answer 35

Name of pt
Address of pt
Age of pt
Name of drug. (use generic name not trade name) 
Format of drug (Eg oral suspension)
Dose of drug (avoid decimal points)
Frequency (avoid abbreviations Eg tds)
Duration

Question 36

What is chlorhexidines mode of action

Answer 36

At physiologicpH, chlorhexidine salts dissociate and release the positively charged chlorhexidinecation. The bactericidal effect is a result of the binding of this cationic molecule to negatively charged bacterial cell walls. At low concentrations of chlorhexidine, this results in abacteriostaticeffect; at high concentrations, membrane disruption results in cell death.[14]

Question 37

What is chlorhexidine

Answer 37

is adisinfectantandantisepticthat is used forskin disinfectionbefore surgery and to sterilizesurgical instruments.[2]It may be used both to disinfect the skin of the patient and the hands of the healthcare providers.[3]It is also used for cleaningwounds, preventingdental plaque, treatingyeast infections of the mouth

Question 38

What is benzydamine

Answer 38

Benzydamine, available as the hydrochloride salt, is a locally-acting nonsteroidal anti-inflammatory drug with local anaesthetic and analgesic properties for pain relief and anti-inflammatory treatment of inflammatory conditions of the mouth and throat

Question 39

What is lidocaine

Answer 39

also known aslignocaine, is a medication used tonumb tissue in a specific area(local anesthetic).[4]It is also used to treatventricular tachycardiaand to performnerve blocks.[3][4]Lidocaine mixed with a small amount ofadrenaline(epinephrine) is available to allow larger doses for numbing, to decrease bleeding, and to make the numbing effect last longer.[4]When used as an injectable, lidocaine typically begins working within four minutes and lasts for half an hour to three hours.[4][5]Lidocaine mixtures may also be applied directly to the skin ormucous membranesto numb the area
Lidocaine is anantiarrhythmic medicationof the class Ib type.[3]This means it works byblocking sodium channelsand thus decreasing the rate of contractions of the heart.

Question 40

What is the mechanism of action of lidocaine

Answer 40

Lidocaine alters signal conduction inneuronsby prolonging the inactivation of the fastvoltage-gated Na+channelsin the neuronal cell membrane responsible foraction potentialpropagation.[36]With sufficient blockage, the voltage-gated sodium channels will not open and an action potential will not be generated. Careful titration allows for a high degree of selectivity in the blockage of sensory neurons, whereas higher concentrations also affect other types of neurons.

The same principle applies for this drug’s actions in the heart. Blocking sodium channels in the conduction system, as well as the muscle cells of the heart, raises the depolarization threshold, making the heart less likely to initiate or conduct early action potentials that may cause an arrhythmia

Question 41

What are tetracyclines

Answer 41

Tetracyclinesare a group of broad-spectrumantibioticcompounds that have a common basic structure and are either isolated directly from several species ofStreptomycesbacteriaor produced semi-synthetically from those isolated compounds

Tetracyclines are growth inhibitors (bacteriostatic) rather than killers of the infectious agent (bacteriocidal) and are only effective against multiplying microorganisms.[1]They are short-acting and passively diffuse throughporin channelsin the bacterial membrane.

Question 42

What is chrohns disease

Answer 42

Crohn’s diseaseis a type ofinflammatory bowel disease(IBD) that may affect any segment of thegastrointestinal tractfrom themouthto theanus.[2]Symptoms often includeabdominal pain,diarrhea(which may be bloody if inflammation is severe),fever, andweight loss.[1][2]Other complications outside the gastrointestinal tract may includeanemia,skin rashes,arthritis,inflammation of the eye, andtiredness.[1]The skin rashes may be due to infections as well aspyoderma gangrenosumorerythema nodosum.[1]Bowel obstructionmay occur as a complication of chronic inflammation, and those with the disease are at greater risk ofbowel cancer

Question 43

What are carbamazepines?

Answer 43

Carbamazepine, sold under the trade name Tegretol among others, is an anticonvulsant medication used primarily in the treatment of epilepsy and neuropathic pain. It is not effective for absence or myoclonic seizures.

Question 44

What is the mechanism of action of carbamazepine

Answer 44

Carbamazepine is asodium channel blocker.[28]It binds preferentially to voltage-gated sodium channels in their inactive conformation, which prevents repetitive and sustained firing of an action potential. Carbamazepine has effects on serotonin systems but the relevance to its antiseizure effects is uncertain. There is evidence that it is aserotonin releasing agentand possibly even aserotonin reuptake inhibitor.