Transcript Pharmacology - All Online!

Oral Conditions & Their Treatment
1
Acute Necrotizing Ulcerative
Gingivitis (ANUG)
Definitions:
 a.k.a Vincent’s infection or trench
mouth
 develops with bacteriologic
(spirochetes) and environmental
(stress, debilitation) factors
 spreading ulcer with distinctive odor;
begins at the interdental papillae
i)
2
Acute Necrotizing Ulcerative Gingivitis (ANUG)
Treatment:

good oral hygiene

mouthwashes – hydrogen peroxide or saline rinses
(flushing), if bacterial type of infection (saline rinse)

aspirin or acetaminophen if pain or ↑ temperature
exists

food supplements if difficulty eating

vitamin supplements if vitamin deficiency

antibiotics ONLY IF immunosuppressed or systemic
infection exists → penicillin VK or metronidazole

topical chlorhexidine gluconate – rinse effective on
g+, g- and Candida organisms\

DRAMATIC RESPONSE to oral prophylaxis with
scaling
i)
3
Herpes Infections
Primary herpetic gingivostomatitis
ii)



Read p259-261 (Herpes review)
SHOULD KNOW-Treatment options
-acyclovir as ex.
iii)


Candidiasis
Read p261
SHOULD KNOW-Treatment options
4
iv)
Angular Cheilitis / Cheilosis
Definitions:

cracks in the corners of the mouth

appearance: redness, fissures, erosion, ulcers
& crusting; WITH or WITHOUT pain

most cases → mixed infection → Candida
albicans plus g+ bacteria

occurs as a result of drooling

treatment: treat the secondary infection
5
iv)
Angular Cheilitis / Cheilosis
Treatment:

if Candida – topical antifungal agents such as
nystatin, clotrimazole, miconazole

if inflammation – antifungal mixed with a topical
steroid such as Mycolog (Mycostatin + Kenalog)

if bacterial overgrowth – systemic penicillinaseresistant penicillins such as dicloxacillin
•
•
newer antibiotic mupirocin (Bactroban) – topical antibiotic
that ↓ likelihood of adverse reactions & is as effective as
penicillinase-resistant penicillins
mupirocin + topical antifungal agent can be used together if
indicated
6
v)
Alveolar Osteitis
Definitions:

a.k.a. “dry socket”

occurs as a result of tooth extractions but
uncommon (only in 2-3% of cases)

most common in the lower molar areas

caused by loss or necrosis of the blood clot
formed at extraction site thus, exposing the
underlying bone → severe pain!
7
v)
Alveolar Osteitis
Predisposing Factors:

BCP’s & the menstrual cycle, smoking (negative
pressure) and diabetes
Symptoms:

infection, swelling, ↑ temperature, lymph-adenopathy and a foul odour
Treatment:

saline rinses, debridement, dry socket pack &
analgesics

antibiotics – ONLY IF infection present or in patients
at high risk of infections (treatment not prophylaxis)
8
i)
Recurrent Aphthous Stomatitis (RAS)
Definitions:

a.k.a. “canker sore”

common oral lesion occurring in about 20% of the population

unknown etiology – involvement of the immune system
suspected

presents as a few small to many large ulcers (can also
coalesce into giant ulcers)

3 different types: minor, major & herpetiforme
•

minor most common – flat, white lesion on the mucosa
hypotheses on etiology: allergenic / hypersensitivity, genetic,
hematologic, hormones, infection, nutrition, trauma & stress
also some question OTC toothpastes that contain sodium lauryl
sulfate
*Know table 14-2* Dentifrices that do not contain sodium lauryl sulfate
•
9
i)
Recurrent Aphthous Stomatitis (RAS)
Treatment:
1.
corticosteroids – reduce inflammation
-
example: fluocinonide and betamethasone
carboxymethylcellulose paste (Orabase) – hardens into a
plasticlike plaster (steroids in this paste)
severe cases, systemic steroids given
amelorex (Aphthasol) - topical
2.
3.
4.
-
↓ duration of both healing & pain
diphenhydramine (die-fen-hydra-mine)
preferred due to its L.A. action
antihistamine
immunosuppressives
last resort to treat severe aphthous
example: azathioprine (Imuran) & cyclosporin
(Sandimmune)
10
ii)
Lichen Planus
Definitions:

skin condition with frequent oral lesions on the mucous
membranes

oral lesions present without skin lesions in 65% of cases

3 types: striated, plaquelike & erosive

hypertrophic type (erosive) the most prevalent – white lacelike pattern
Symptoms:

varying pain from no pain to extreme pain depending on the
presence of ulcerations
Etiology:

unknown

hypotheses – viral infection, an autoimmune disease &
hypersensitivity reaction to an unknown agent (toothpaste)
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i)
Geographic Tongue
Definitions:

world map like lesions on tongue with lesions
appearing to be the continents

ringed lesions with erythema – centers are white

changes in patterns over time & may also disappear
at times
Etiology:

unknown; relations to hormonal changes, stress,
infection, psoriasis, or autoimmune diseases

burning becomes severe with spicy foods or alcohol
Treatment:

reassurance and avoidance of irritating food &
alcohol
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ii)
Burning Mouth or Tongue Syndrome
Definitions:

a.k.a. glossodynia & glossopyrosis

oral cavity appears normal but patient reports discomfort described
as pain or burning sensation that ↑ in severity through the day

painful tongue with or without observable alterations on the tongue

caused by local or systemic conditions

redness, burning, stinging, or itchiness can occur
Etiology:

unknown; hypotheses – xerostomia, candidiasis, acid reflux,
nutritional deficiency, immunologic, hormonal changes, allergic
reaction, inflammatory process, psychogenic or idiopathic reaction

depression or chronic disease may play a role
Treatment:

depends on practitioner’s beliefs of cause
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i)
Pericoronitis
Definitions:

inflammation of the tissue around the crown of the tooth

most common location: partially erupted third molars (wisdom
teeth)

food & bacteria trapped between the operculum and the tooth
– painful & swelling
Treatment:

debridement with saline irrigation and warm saline rinses

extraction if indicated

repeated episodes could occur with partially erupted third
molars

analgesics: for discomfort

infection: in debilitated patients could spread rapidly thus, treat
with antibiotics
14
ii)
Postirradiation Caries
Definitions:

changes in saliva after irradiation therapy &
lack of proper plaque control can rapidly ↑
rate of dental caries

cervical decay evident after the first year
Treatment:

meticulous oral hygiene, frequent cleanings,
artificial saliva's, self-administered fluoride
gel 4 time daily (extreme cases) in a bite
guard
15
iii)
Root Sensitivity, recession
Definitions:

sensitivity of exposed root surfaces precipitated by
heat, cold, sweet or sour foods; even scaling

occlusal trauma – adjustment is treatment

periodontal surgery, extensive root planing, or
accumulation of plaque can also cause sensitivity
Treatment:

difficult to manage; glycerin, sodium fluoride,
stannous fluoride, adrenal steroids

desensitizing toothpastes help some patients but
research lacking
16
iv)
Actinic Lip Changes
Definitions:

long-term exposure of lip to the sun → irreversible
tissue changes known as actinic cheilitis

near vermillion border & could lead to malignancy
Treatment:

sunscreen (higher that 15 protection)

if keratotic changes – antineoplastic agent that
promotes sloughing( example: 5-fluorouracil)- (5-FU)


topical steroid may be used to relieve irritation produced by
5-FU
Common cream, used daily
17
Xerostomia
Sjögren’s syndrome
i)
Definitions:

dry mouth

may result from a drug (e.g. atropine), a disease,
aging or radiation

many drug groups can produce xerostomia such as
anticholinergics and other drugs with
anticholinergic side effects

can produce ↑ in incidence of caries (especially
Class V lesions)
18
i)
Xerostomia
Treatment:
1.
caries prevention
2.
3.
4.
5.
-
fluoride trays & gels
-
fluoride rinses or trays
water & sugarless gum; NO sugar gum or candy
-
depending on indications for use
artificial saliva
home care
change medication or reduce dose
Pilocarpine a cholinergic agent
- P+; increases saliva (sialorrhea,sialosis, and sialism)
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ii)


Sialorrhea
a.k.a. sialosis or sialism
certain drugs can increase in saliva; example: pilocarpine
Hypersensitivity-Type Reactions
may be hyperimmune responses to an antigenic component of
the drug
contact stomatitis – localized with gum or candy & diffuse with
toothpaste
buckle mucosa & lateral borders of tongue involved
cinnamon flavoured products can produce this response
potential for reaction depends on: particular drug, frequency and
route of administration (topical Ab’s more likely to cause rx),
patient’s immune system
iii)





20
iv)
1.
2.
Oral Lesions That Resemble Autoimmune-Type
Reactions
Lupus-like reactions:


oral lesions occurring with lupus erythematosus
also produced with antiarrhythmic & anticonvulsant drugs

drugs such as anticonvulsants can produce lesions that
resemble this
Erythema multiforme-like:
Stains
primary or adult dentition
tetracyclines are main group of drugs causing stains
chlorhexidine rinse as well as liquid iron can cause
extrinsic stains
v)



21
Gingival Enlargement
a.k.a. gingival hyperplasia
can occur most commonly with:
vi)


•
•
•
•
phenytoin (Dilantin): half the patients exhibit this
reaction; oral hygiene must be meticulous
cyclosporin (Sandimmune): antirejection drug –
kidney transplant & other transplants
calcium channel blockers (CCB): used for
hypertension & congestive heart failure (CHF)
other: carbamazepine (Tegretol) – anticonvulsant
Corticosteroids
used for inflammation or immune response
depending on severity of lesions, topical
corticosteroids selected based on their potency
i)


•
•

•

•
weak, intermediate or potent used in turn until agent is
effective
hydrocortisone cream 1% is popular OTC
if topical ineffective or condition severe, systemic
corticosteroids may be used
most common: prednisone
if chronic systemic corticosteroids need to be used
then adverse reactions must be managed:
osteoporosis, fluid retention, diabetes, hypertension, moon
face &buffalo hump
Palliative Treatment
designed to make patient more comfortable
topical or systemic agents to ↓ pain in oral cavity
(sometimes can be used together for pain
management)
systemic analgesics can often provide relief from a
painful oral lesion
topical local anesthetics could cause reduction of
sensations of throat leading to possible choking
isolated lesions: paint on the anesthetic with cotton
swab
ii)





DH1 – PHAR/EMG
DH1 – PHAR/EMG
 cardiovascular
disease (CVD): various
diseases of the heart & blood vessels
• leading cause of death; 25% of top 200 drugs
from this group
• examples: hypertension (↑ blood pressure),
angina pectoris, cerebrovascular accident
(CVA), congestive heart failure (CHF) &
hypercholesterolemia (↑ cholesterol)
• medical histories are a VERY important identifier
of CVD & the accompanying list of one or more
medications
DH1 – PHAR/EMG
Contraindications To Treatment
certain circumstances dictate that dental
procedures may be delayed until CVD
under better control
absolute contraindications are
highlighted on page 273 (Box 15-1)
these absolute contraindications apply
only to uncontrolled or severe CVD
i.



DH1 – PHAR/EMG




ii. Vasoconstrictor Limit
majority of CVD can have L.A. with
vasoconstrictor – epinephrine; severity of the
disease must be considered
endogenous epinephrine could be released
anyways, if we have poor pain management,
so epinephrine in L.A. may be useful
limit epinephrine to cardiac dose (0.04 mg) in
severely affected patients
use slow rate of injection & appropriate
aspiration techniques
DH1 – PHAR/EMG
iii. Infective


Endocarditis
if rheumatic heart disease or other
valvular or degenerative disease
discovered on medical history, risk of
producing infective endocarditis
present
prophylactic antibiotics should be
considered
DH1 – PHAR/EMG
Cardiac Pacemakers
an electrical device implanted into patient’s
chest to regulate heart rhythm
if not shielded properly, some devices used in
dentistry (ex. cavitron) may interfere with
activity of pacemaker; get medical clearance
patients DO NOT require prophylactic
antibiotics
v. Periodontal Disease & CVD
studies show that presence of periodontal
disease predicts an ↑ in morbidity & mortality
resulting from CVD
iv.




DH1 – PHAR/EMG
Definitions
 the heart is a pump: adequate circulation of blood to
meet oxygen needs of body
 when needs ↑ (ex. exercise), normal heart adjusts the
output
 Congestive Heart Failure (CHF): a “failing” heart; the
heart does not provide adequate cardiac output to
provide for the oxygen needs of the body
• occurs when heart suffers injury (myocardial infarction,
•
•
•
•
arrhythmias, valvular abnormalities, rheumatic heart disease)
enlargement takes place (ok at first but later too much
enlargement) thus, too much blood to pump out – tachycardic
usually, left side fails first → blood backs up into lungs →
pulmonary edema → dyspnea & orthopnea
dental patients – semi-reclined position
if right side failure → systemic congestion → peripheral edema
(pedal edema)
DH1 – PHAR/EMG
Definitions
 arrhythmia & dysrhythmia used synonymously
to mean “abnormal rhythm”
 results from abnormal impulse generation or
abnormal impulse conduction
 cardiac diseases such as arteriosclerosis &
heart block can produce arrhythmias
 antiarrhythmic agents used to prevent
arrhythmias
 various types of arrhythmias – divided into:
• supraventricular (atrial)
• ventricular

can cause tachycardia or bradycardia
DH1 – PHAR/EMG
Antiarrhythmic Agents
work by depressing parts of the heart
that are beating abnormally
examples of specific action of these
drugs:
i.


•
•
•

↓ velocity of depolarization
↓ impulse propagation
inhibition of aberrant impulse propagation
digoxin – not classified as an
antiarrhythmic drug but used as one;
toxic doses can cause ventricular
arrhythmias
DH1 – PHAR/EMG
Adverse Reactions
antiarrhythmic agents are difficult to
manage therefore, only used in patients
with arrhythmias that prevent proper
functioning of the heart
ii.

DH1 – PHAR/EMG
Definitions:
 angina pectoris: common cardiovascular disease
characterized by pain or discomfort in the chest
radiating to the left arm or shoulder; sometimes
radiating to the neck, back & lower jaw (can be
confused with a toothache)
 coronary arteries do not supply enough O2 to the
myocardium for its current work
 anginal pain precipitated by stress, physical exercise or
emotional (anxiety of dental appt.)
 pharmacologic effects of antianginal agents - ↓ C.O., ↓
peripheral vascular resistance or both; thus, O2
requirement of heart ↓ - reduces pain
 anginal episode can occur at any time & have
emergency procedures ready
 antianginals reduce symptoms only; not curative
DH1 – PHAR/EMG
Nitroglycerine-Like Compounds
nitroglycerine (NTG) – most frequently used
nitrate for management of angina induced by
stress or exercise
also used to manufacture dynamite
vasodilator – relaxation of vascular smooth
muscle throughout the body
↓ O2 demand
tolerance can occur unless a nitrate-free
period is observed daily
i.





DH1 – PHAR/EMG
Nitroglycerine-Like Compounds
Sublingual Nitroglycerin
used to treat acute anginal attacks
rapid onset (minutes); lasts up to 30 mins.
sublingual tablet - Nitrostat
sublingual spray - Nitrolingual
dental patients usually bring these agents with
them or should be reminded to do so & should
be kept ready on the bracket table
dental office emergency kit should contain
these meds
i.






DH1 – PHAR/EMG
Nitroglycerine-Like Compounds
Adverse Reactions
severe headaches (vasodilation)
flushing
hypotension (enhanced by alcohol & hot
weather)
light-headedness
syncope
localized burning or tingling at site of
administration (with sublingual NTG)
i.






DH1 – PHAR/EMG
Nitroglycerine-Like Compounds
Storage
NTG degraded by heat & moisture; NOT by
light
should be stored in original brown glass
container; tightly closed; do not refrigerate
unopened bottle: active until expiration
opened bottle: date opened should be written
on outside of the bottle & the medication
should be discarded between 3-6 months
NTG spray: until expiration date (no air in
bottle)
i.





DH1 – PHAR/EMG
Nitroglycerine-Like Compounds
long-acting NTG-like products such as
isosorbide dinitrate used for prophylaxis
of anginal attacks
tablets & topical ointment, patch
products available
with long-term, regular use, tolerance
develops – 8-12 hour “vacation”
everyday needed to prevent this
i.



DH1 – PHAR/EMG
Calcium Channel Blocking Agents
CCB’s inhibit movement of Ca+ during contraction of
cardiac & smooth muscle
some CCB’s ↓ myocardial contractility (↓ C.O.) & others
↑ coronary vasodilation
also used for arrhythmias & hypertension
adverse reactions include constipation & hypotension
ii.




•
nifedipine – gingival enlargement (like Dilantin) &
dysgeusia
 frequent appt’s & meticulous oral hygiene

examples:
•
•
•
vera-pam-il (Calan, Isoptin)
dil-tia-zem (Cardizem)
ni-fed-ipine (Procardia, Adalat)
DH1 – PHAR/EMG
Dental Implications
Treatment of acute anginal attack
 be prepared! Have emergency kit with NTG in
supply & not expired
 place NTG on bracket table
 if needed, sublingual NTG should be
administered while seated upright
 one tablet at once, 5 mins later – another one
and 5 mins later – another one
iv.
•

if this does NOT help, go to emergency
do not inhale if using spray-type NTG
DH1 – PHAR/EMG
Dental Implications
Prevention of anginal attacks
 pretreatment with an anxiolytic
(benzodiazepine or N2O) or with sublingual
NTG
 anxiolytic - ↓ anxiety & ↓ stress on heart; N2O
relaxes as well
 NTG – give as a premedication to anxietyprovoking dental procedure such as L.A.
Myocardial Infarction (MI)
 if anginal attack not relieved by 3 doses of SL
NTG, MI could be suspected → take to emerg
iv.
DH1 – PHAR/EMG
Definitions:
Categories for hypertension:
 essential
• 85-90% of cases; treated with antihypertensive drugs
• a.k.a. idiopathic or primary; unknown cause

secondary
• 10% of cases; associated with other disease such as endocrine
or renal disease; treat initial cause/disease
• steroids, NSAIAs, BCPs, decongestants & antidepressants can
produce

malignant
• small # of cases (5% of people with primary or secondary
hypertension); BP very high or rapidly rising
• evidence of retinal or renal damage exists
DH1 – PHAR/EMG
Stepped-Care Regimen
 pharmacologic management of HT involves
stepped-care approach
• Step 1
 lifestyle changes: ↓smoking, ↓stress, ↓weight, ↓salt,
↑exercise
• Step 2
 therapy with “Big 5” group of antihypertensive drugs
 several drugs from different groups can be used; ↓side
effects
 diuretics (> 50 yo’s) and peripheral vascular disease
 β –Blockers (< 50 yo’s) and ischemic heart disease
• Step 3
 ↑ dosage; combined with other drugs –
vasodilators/adrenergic blockers
• Step 4
 mixing 2-3 drugs already mentioned
DH1 – PHAR/EMG
Dental Considerations:
 regardless of medication usage, BP of
each HT patient should be measured &
recorded
 patients should be questioned about
compliance re: their antihypertensive
medication
 abrupt discontinuation could cause
rebound hypertension – BP rises to
higher level than it was before treatment
DH1 – PHAR/EMG
i.
Diuretic Agents
3 types:
A. Thiazide Diuretics
B. Loop
C. Potassium-sparing
DH1 – PHAR/EMG
i.
A.
Diuretic Agents
Thiazide Diuretics
Adverse Reactions:

hypo-kal-emia - ↓K+ - could cause arrhythmias; if patient taking
digoxin, potential for arrhythmias exacerbated

hyper-uricemia -↑uric acid in blood – watch out for patients with gout

hyper-glycemia – watch out for diabetics

hyper-lipid-emia - ↑fats/lipids

hyper-ca-lcemia - ↑ Ca+

anorexia - ↓appetite / food aversion

oral: xerostomia, oral lichenoid eruptions
•



reversible on discontinuation of meds (with time)
NSAIAs (usually used by patients for arthritis) ↓ antihypertensive
effect of HCTZ – takes few days to manifest so a few days of NSAIA
okay for acute pain; HT meds have to be adjusted for chronic usage
limit epinephrine to cardiac dose
thiazides potentiate action of other antihypertensives → hypotension
DH1 – PHAR/EMG
β-Adrenergic Blocking Agents
suffix of drugs -olol
propranolol – blocks both β1 & β2 receptors
selective β-blockers (β1 > β2) have advantages
in patients who may have asthma
less likely to produce a drug interaction with
epinephrine
these drugs lower BP by ↓C.O.
usually used in step 2 therapy – alone or in
combination with other antihypertensive
drugs
ii.

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DH1 – PHAR/EMG
iii. Calcium
Channel Blocking Agents
Pharmacologic Effects:
 smooth muscle – vascular smooth
muscle relaxed, dilation of coronary &
peripheral arteries & arterioles →
reduces preload
 cardiac muscle - ↓HR, ↓contractility &
conduction
DH1 – PHAR/EMG
Angiotensin – Related Agents
A. Angiotensin-Converting Enzyme Inhibitors
(ACEIs)
 a complex homeostatic mechanism involved
in maintaining BP
 usually have suffix -pril
 examples:
iv.
•
•
•
capto-pril (Capoten)
en-ala-pril (Vasotec)
lis-ino-pril (Prinivil, Zestril)
DH1 – PHAR/EMG
Niacin
a.k.a. nicotinic acid; a B vitamin
in large doses – therapeutic effect –
lowers cholesterol levels
causes flushing in the face & neck
region –blocked by pretreatment of 0.3
gm of aspirin or 1 tablet of ibuprofen
daily
dental implications – hypotension –
watch getting up from dental chair
ii.
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DH1 – PHAR/EMG
Dental Implications:
 those who take these medications have a
higher risk of arteriosclerosis and
cardiovascular emergencies such as MI’s
and cardiac arrest
 be prepared to handle these
emergencies
 check BP and HR at each appointment &
note preemergency BP and HR – to
compare
DH1 – PHAR/EMG

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
Anticoagulants
drugs that interfere with coagulation
administered in order to prevent
coagulation
indications: MI or thrombophlebitis
warfarin (Coumadin) – most important
anticoagulant and used almost
exclusively
DH1 – PHAR/EMG




Hemostasis
normal mechanism in body is to prevent loss of blood
after injury to a blood vessel; leaking vessel is plugged
by a complicated process of clot formation
if blood vessel’s interior remains smooth, circulating
blood does not clot; if internal injury to vessel occurs
(roughness), intravascular clotting will take place
these intravascular clots (thrombi) can also develop in
certain diseases; if break off, emboli can lodge into
smaller vessels of major organs such as the heart, brain
& lungs – producing severe or even fatal
thromboembolic disease
anticoagulant therapy reduces the chance of these lifethreatening situations BUT if too large a dose,
hemorrhage can develop; if dose too small, risk of
embolism remains
DH1 – PHAR/EMG
Warfarin (Coumadin)
oral anticoagulant
orally effective & less expensive than heparin
pharmacologic effect is delayed when therapy
begins & ends – be careful when reducing
dose
monitor using International Normalized Ratio
(INR) (time it takes in seconds for blood to
clot)
i.




•
•
therapeutic range: 2.5 – 3.5
can range between 1 – 4 (overdose – higher)
DH1 – PHAR/EMG
Warfarin (Coumadin)
Adverse Reactions:
 hemorrhage
 petechial hemorrhages on hard palate
 ecchymoses – even without trauma
 no advantage in higher doses of
warfarin but increase in adverse
reactions
i.
DH1 – PHAR/EMG
Warfarin (Coumadin)
Adverse Reactions To Other Drugs:

aspirin:
i.
•
•
•
•
•


acetaminophen & opioids: OK
antibiotics:
•
•
•
•

most serious interaction – no aspirin or aspirin containing
products (cold meds)
could be fatal hemorrhaging
irritates the GI as well; could bleed here too
if NSAIA – ibuprofen or naproxen – OK
nonacetylated salicylates – no effect
potentiate effect of warfarin (added anticoagulant effect)
SEE Table 15-14 p 361 for more details
clindamycin is the best choice
BE CAREFUL when giving prophylaxis – the interaction would
not have a chance to develop
phenobarbitol: reduces its effect
DH1 – PHAR/EMG
Warfarin (Coumadin)
Management Of The Dental Patient Taking Warfarin
**** SEE Box 15-15 p 311 for details
**** READ Box 15-10 p 312
Analgesics:
i.



aspirin & aspirin containing products absolutely
contraindicated unless patient taking aspirin daily for
its anticoagulant effect – then monitor
acetaminophen or any opioid alone or together ok for
analgesia
few doses of ibuprofen or naproxen – ok if no other
contraindication to their use
DH1 – PHAR/EMG








epilepsy – group of disorders that involve recurrent
attack of involuntary behaviour or experience or
changes in neurologic function caused by electrical
activity in the brain; can be recorded via
electroencephalogram (EEG)
localized or generalized effect
episode termed seizure
may be accompanied by convulsions
1% of the population
anticonvulsants used chronically; evident adverse
reactions
majority of patients have idiopathic epilepsy (unknown
cause)
can have aura – sensation through migraine or seizure,
of movement or discomfort or emotions
DH1 – PHAR/EMG
2 major groups of seizures:
generalized (subdivided into 2 groups)
1.
a.
b.
absence seizures (petit mal) ***
tonic-clonic seizures (grand mal) ***
***most common
Partial (focal)
2.
•
•
absence seizures (petit mal)
tonic-clonic seizures (grand mal)
DH1 – PHAR/EMG
Absence Seizures
a.k.a. petit mal
brief (few seconds) loss of consciousness
little movement
usually begin in childhood & disappear in
middle age
patients unaware of occurrence & body tone
not lost
no aura; patient quickly recovers
drug therapy: ethosuximide or valproic acid
a.







DH1 – PHAR/EMG
Tonic-Clonic Seizures
a.k.a. grand mal
longer unconscious periods
major motor activity
at first, body becomes rigid, patient falls to floor
urination, apnea & a cry may be present
tonic rigidity followed by jerking of face, limbs &
body; sometimes violently – can cause serious injury
to self
patient can bite cheek or tongue
finally patient becomes limp & comatose
gradual return for consciousness followed by
confusion
true aura does not occur
drug therapy: valproic acid, phenytoin,
phenobarbital, carbamazepine
b.











DH1 – PHAR/EMG
Status Epilepticus
continuous tonic-clonic seizures that last >
30 minutes
emergency situation
tissues could be hypoxic (lack of oxygen);
rapid therapy required
drug therapy: parenteral benzodiazepines
ex. diazepam (Valium)
c.




DH1 – PHAR/EMG



involve activation of only part of the brain
location of activity determines manifestation
elementary (simple) partial attack:
• consciousness NOT impaired

complex partial attack:
•
•
•
•

consciousness impaired; slow to return
a.k.a. psychomotor or temporal-lobe
last several minutes (whereas absence – few secs)
may have aura
drug therapy: carbamazepine, phenytoin,
phenobarbital
DH1 – PHAR/EMG
 goal: control
seizures & minimize adverse
effects
 anticonvulsants are CNS depressants –
help prevent seizures without drowsiness
 exact mechanism of action unknown
 used for life – therefore consider chronic
toxicity before choosing anticonvulsant
DH1 – PHAR/EMG

CNS:
•
•
•
•
•


General Adverse Reactions of Anticonvulsants
depressed CNS
tolerance develops to sedative effects but not to anticonvulsant effect
impaired learning & cognitive abilities can occur
hyperactivity & sedation
CNS depression additive with other CNS depressants such as opioids
GI: take drugs with food
drug interactions:
• may interact with themselves, each other or with other drugs
• most important: stimulation of hepatic microsomal enzymes – causes
•
•
•
•
reduction in blood level of affected drugs
if level too high – toxicity; too low – loss of seizure control
idiosyncratic reactions – include rashes
teratogenicity exists; impaired growth
withdrawal: abrupt withdrawal can precipitate seizures
DH1 – PHAR/EMG
Phenytoin (Dilantin)
tonic-clonic & partial seizures with
complex symptomatology; also used for
trigeminal neuralgia; has antiarrhythmic
properties
NOT useful alone for pure absence
seizures
iv.


DH1 – PHAR/EMG
Phenytoin (Dilantin)
Adverse Reactions
gingival enlargement:
iv.

•
•
•
•
seen in in 50% of chronic users
appear in a few weeks to as long as a few years
after initial drug therapy; need good OH to
control enlargement
etiology – unknown
management:
 alter the drug if possible
 after discontinuation: gingival reduction occurs
but may take awhile to develop – wait 18 months
min for surgery
 improve OH & ↑ recalls
 gingivectomy: enlargement returns if continued
use of drug
DH1 – PHAR/EMG





be prepared for emergency situation
educate whole dental team on handling these
patients, management, drugs etc.
take detailed seizure history
avoid excessive stress & missed medications
management of tonic-clonic seizure:
• move patient to floor if possible
• tilt head to one side – prevent aspiration
• remove objects from mouth before seizure – prevent tooth
fracture
• loosen tight clothing
• DO NOT use tongue blades or others – could cause more
damage
DH1 – PHAR/EMG
 neurologic
pain:
• carbamazepine – trigeminal neuralgia & atypical facial
pain
• phenytoin – neurologic pain
• valproic acid – migraine headache prophylaxis
 psychiatric
use:
• carbamazepine, valproic acid, clonazepam &
gabapentin – used as “mood stabilizers” in bipolar
disorders
 THUS, patient
taking anticonvulsants may or may
not have a seizure disorder – CHECK med
history!!!
DH1 – PHAR/EMG
congenital or caused
by disease or injury
Psychiatric Disorders
Organic
(Primary)
Functional
(Secondary)
Psychoses
Affective
Disorder
ex. schizophrenia
Tx: antipsychotics
ex. bipolar
depression
partially of
psychogenic
origin
Neuroses
(Anxiety)
ex. phobias,
panic disorders &
obsessive-compulsive
disorder
Tx: antidepressants Tx: minor tranquilizers
& lithium
(see Chapter 11)
DH1 – PHAR/EMG
Psychoses
 Schizophrenia most common
 extensive disturbance of patient’s
personality function with loss of reality
 not into multiple personalities
 inability to function in society
 delusions & paranoia “someone’s out to
get me” – could lead to serious crimes
 unknown etiology; familial suspected
DH1 – PHAR/EMG
Affective Disorders
 unipolar depression (only depression)
• endogenous –unrelated to external events
• exogenous – related to external events
 bipolar
depression (mania)
• alternating moods between depression &
excitation (mania)
DH1 – PHAR/EMG
Neuroses
 less severe than psychoses
 examples:
•
•
•
•
anxiety
panic disorders
phobias
obsessive-compulsive disorder (OCD)
 treatment (anxiety-related disorders):
• benzodiazepines (clonazepam) (see Chapter
11)
DH1 – PHAR/EMG
 electroconvulsive
therapy (ECT, shock) still
used in treatment of depression, with use
of neuromuscular blocking agents – makes
ECT safer
 produces fastest results
 used for people who do not respond to
antidepressants
 memory loss may occur
DH1 – PHAR/EMG
General Precautions for Treating Patients
with Mental Disorders
 communication – may view comments or
movements from the dental health care
worker as threatening
 compliance – patients often do not take
their medication as prescribed
 suicide – may attempt suicide – drugs
often combined
DH1 – PHAR/EMG
 phenothiazines
- most frequently used for
outpatient treatment
 “atypical” antipsychotics – newer meds for
patients who were resistant to typical
antipsychotics
 low-potency agents, ex. chlorpromazine
(Thorazine) have more sedation, more peripheral
side effects & more autonomic effects (ex.
xerostomia) than high-potency agents, ex.
haloperidol (Haldol) (less sedation and more
extrapyramidal effects)
DH1 – PHAR/EMG

antipsychotic
•
•
•
•

all phenothiazines possess this effect – suppression of
hallucinations & delusions
active against positive effects but little on negative effects
newer agents better for schizophrenia
if used as an antipsychotic, all other effects considered
adverse reaction, even antiemetic
antiemetic
•
•

Pharmacologic Effects
a. phenothiazines
depression of trigger zone in brain that causes nausea &
vomiting; used also as a treatment for hiccups
if used as an antiemetic, all other effects considered
adverse reaction, even antiemetic
potentiation of opioids
DH1 – PHAR/EMG


General Adverse Reactions to Antipsychotic Agents
sedation – unlike sedative-hypnotics, phenothiazines do
not produce anaesthesia at higher doses & patient is
easily aroused
extrapyramidal effects – most common; all
phenothiazines produce this effect
•
•
•
•
acute dystonia – muscle spasms of face, tongue, neck & back
Parkinsonism – resting tremor, rigidity & akinesia
akathisia – increased compulsive motor activity
tardive dyskinesia – irreversible dyskinesia of tongue, lips, face
& jaw (voluntary muscle performance)
 typically in women > 40 years old; large doses min 6 months – 2 yrs
or as long as 20 years
 movements coordinated & rhythmic; exacerbated with drug
withdrawal
 makes home care difficult; performing oral prophylaxis difficult
• intermittent, severe TMJ pain – counteract the extrapyramidal
effects like this by giving anticholinergics like benztropine
(Cogentin)
DH1 – PHAR/EMG
Dental Implications
 sedation – additive with other sedatives
 anticholinergic effects – patients may use sugarcontaining candy to counter xerostomia –
educate them! Use sugar-free and artificial
salivas (ex. Xero-Lube)
 orthostatic hypotension – raise chair slowly &
assist patient
 epinephrine – ok with L.A. but NOT for fainting
 TMJ – may have spasms
 tardive dyskinesia – irreversible; report to G.P.
DH1 – PHAR/EMG
 used
not only to manage depression but
also chronic pain & migraine headache
prophylaxis, therefore do not assume
patient is depressed – question thoroughly
 in the case of suicidal thoughts, ECT works
faster than any antidepressant
DH1 – PHAR/EMG
lithium (Eskalith, Lithobid)
used in treatment of bipolar (manic) depression
cyclic recurrence of mania alternating with depression
side effects minimized by monitoring lithium levels
i.



•

observe for signs of toxicity
•



polyuria, fine hand tremor, thirst, slurred speech, ataxia,
nausea, vomiting & diarrhea
CNS symptoms include – muscle rigidity, hyperactive
deep reflexes, excessive tremor
salt intake & sweating change lithium levels
NSAIAs - ↑ lithium levels
ii. anticonvulsants
manic phase – carbamazepine, valproate &
gabapentin; reserved for lithium-resistant cases
DH1 – PHAR/EMG
 autacoids
– “self remedy”
• occur naturally in the body
• produced by many tissues
• formed by the tissues on which they act
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 Almost
all mammalian tissues contain &
can synthesize histamine.
 Stored in mast cells – are cells present in
most tissues that release substances in
response to allergens; symptoms include
such responses as inflammation.
 allergic reaction → mast cells degranulate
→ release histamine & other autacoids
 Histamine is released by normal
reactions, abnormal reactions, or by
administration of certain drugs.
DH1 – PHAR/EMG
there are 2 types of histamine effects:

H1 – agonist effects (discussed this
chapter)
a)
•
•
•
•
b)
•
vasodilation
↑capillary permeability
bronchoconstriction
pain or itching in cutaneous nerve endings
H2 – agonist effects (discussed in chapter
22)
↑gastric acid secretion
DH1 – PHAR/EMG
Adverse Reactions:
 anaphylaxis – severe allergic reaction; possibly
fatal; bronchoconstriction is the predominant
feature
• vasodilation, ↑capillary permeability lead to ↓BP
followed by shock and CV collapse
• fever, shock, loss of consciousness, coma. convulsions
and death may result
 epinephrine
is the drug of choice for treatment
because it works to dilate bronchioles directly
rather than an antihistamine which works to
block bronchoconstriction
DH1 – PHAR/EMG
 a.k.a.
 block
H1-RA, antihistamines, or H1- blockers
the release of histamine at these sites:
• capillary permeability – less tissue edema
• vascular smooth muscle (vessels) – block dilation
• nonvascular (bronchial) smooth muscle – not all
bronchoconstriction blocked by antihistamines
• nerve endings – suppress itching & pain
 be
familiar because:
• may be used for seasonal allergies
• mild allergic reaction to a drug could be treated with
antihistamines
• antihistamine users may have xerostomia
• antihistamine are additive with other CNS depressants
DH1 – PHAR/EMG
4 Common Antihistamines




di-phen-hydra-mine (Benadryl)
chlor-phen-ir-amine (Chlor-Trimeton)
prom-etha-zine (Phen-er-gan)
lora-ti-dine (Claritin)
DH1 – PHAR/EMG



Pharmacologic Effects & Uses:
antiemetic – controls dizziness, nausea & vomiting that
occurs with Meniere’s syndrome; useful in dentistry –
manages post-op nausea & vomiting especially with
opioid agents; ex. promethazine
sedative – ex. diphenhydramine (Benadryl) – high
degree of sedation; used in OTC sleep aids (↑$) like
Nytol ; less expensive as an antihistamine; in dentistry,
hydroxyzine (Atarax) & promethazine (Phenergan)
used pre-op for sedative & antiemetic effect
local anaesthesia – although, antihistamines are not as
effective as other local anesthetics, they can be
administered topical or by injection to provide some
local anesthesia. ex. Benadryl
DH1 – PHAR/EMG





Prostaglandins (PGs) & Thromboxanes (TXs)
Pharmacologic Effects:
smooth muscle
•
•
•
relaxation (vasodilation) or stimulation (vasoconstriction)
GI – produces cramping (↑ motility)
contraction of uterus
•
stimulates & inhibits platelet aggregation
•
used as abortifacients in 2nd trimester & inducers of labor
at full term
platelets
reproductive organs
CNS – increase body temperature
other - ↑HR, CO, capillary permeability, renal blood
flow, sedation & stimulation of pain fibers
DH1 – PHAR/EMG
 PGs
have been implicated in periodontal
disease.
 At least two stages of periodontal disease
may involve PGs.
 First
stage is inflammation of the gingival
tissues, which can lead to erythema,
edema, and increased gingival exudate.
DH1 – PHAR/EMG
 Second
Stage
Resorption of alveolar bone with tooth loss.
PGs also prevent the synthesis of new bone
by inhibiting osteoblastic activity.
Several autacoids have been linked to
periodontal disease: PGs, LTs, and
cytokines.
DH1 – PHAR/EMG
 Leukotrienes
have roles in inflammation.
 They are produced in areas of
inflammation, in blood vessel walls.
 Leukotrienes are also implicated in
asthmatic constriction of bronchioles.
 Anti-asthma medications are the agents
that interfere with leukotriene-receptor
interactions.
DH1 – PHAR/EMG
 These
medications block the binding of
leukotrienes to the receptors on plasma
membranes of the airways of smooth
muscle.
 Therefore, they prevent inflammation of the
bronchioles.
 Newer, and gaining popularity:
 Eg. Singular, and Accolate.
DH1 – PHAR/EMG
 These
medications are leukotriene
inhibitors.
 Can be used for: Mild Persistent Asthma
Moderate Persistent
Severe Persistent
 Or for clients unable to use a metered
dose inhaler (MDI)
DH1 – PHAR/EMG
 Overall, the
safety and incidence of
adverse events are low.
 Two
tissues that merit further discussion
are the potentials for hepatotoxcity and
Churg-Strauss syndrome.
DH1 – PHAR/EMG
 Remain
low, but can rarely cause elevated
hepatic enzymes.
 In severe cases, liver impairments have
been reported.
 If suspected signs and symptoms are
found clinically, leukotriene inhibitor
should be discontinued.
DH1 – PHAR/EMG




Uncommon syndrome that generally occurs in
clients with asthma and allergic rhinitis.
The condition is due to systemic steroid
withdrawal and not necessary a direct effect of
the leukotriene inhibitor.
The condition causes inflammation in a variety of
tissues
Common symptom of this rare syndrome is
eosinophilia (abnormally high levels of WBC’s)
DH1 – PHAR/EMG
 Clinicians
need to monitor clients recently
changing medications from a steroid inhaler to a
leukotriene inhibitor.
 Conditions to watch for:
eosinophilia (↑ levels of WBC’s)
worsening pulmonary inflammation
cardiac complications
neuropathy (involves a change in function
and structure of the peripheral motor and
sensory neurons)
DH1 – PHAR/EMG
 a.k.a. adrenal
corticosteroids,
adrenocorticoids, corticosteroids, steroids
 naturally occurring group of agents
secreted by the adrenal cortex
 dentistry: used topically or systemically
for treatment of oral lesions associated
with inflammatory diseases
 long-term therapy: for chronic systemic
diseases such as asthma or arthritis
DH1 – PHAR/EMG
adrenocorticosteroids
glucocorticoids
•affect intermediate
carbohydrate metabolism
•major glucocorticoid:
cortisol (hydrocortisone)
•discussed in this chapter
mineralocorticoids
•affect water & electrolyte
composition of the body
DH1 – PHAR/EMG
 topically
 orally
– systemic effects rare
 intramuscularly
 intravenously
 systemic
effects with oral & parenteral
administration
 lag time exists in action of steroids
 vasodilation & bronchodilation are also
effects
DH1 – PHAR/EMG
 pharmacologic
effects & adverse reactions
closely related
 effects include anti-inflammatory actions &
suppression of allergic reactions &
suppress the immune response
 palliative rather than curative
DH1 – PHAR/EMG
 proportional
to dosage, frequency & time of
administration, and duration of treatment
 with prolonged therapy & high doses side effects
can occur:
• metabolic changes: moon face/ buffalo hump, truncal
obesity, weight gain & muscle wasting (Cushing’s
syndrome); hyperglycemia
• infections: ↓resistance to infections; masked symptoms
due to antiinflammatory action; in long-term therapy, give
isoniazid (antituberculosis agent)
• CNS: euphoria (↑dose) & depression (↓dose)
DH1 – PHAR/EMG
• peptic ulcer: ↑stomach acid
• impaired wound healing: could cause osteoporosis &
•
•
•
•
impaired growth in children; in alveolar bone – tooth
loss; fractures; muscle wasting
opthamalic: ↑intraocular pressure – glaucoma,
cataracts
electrolyte & fluid balance: those with
mineralocorticoid action, hypertension & CHF could be
exacerbated; hypokalemia
adrenal crisis: suppression; symptoms – syncope, CV
collapse & death
dental: mucosal surfaces heal slowly & more likely to
have infection; with oral steroid inhalers (asthma),
candidiasis
DH1 – PHAR/EMG

replacement
Medical
• Addison’s Disease: hypofunction; hydrocortisone for
glucocorticoid & desoxycorticosterone for mineralocorticoid
• Cushing’s Syndrome: majority of adrenal gland removed –
replacement therapy needed

emergencies
• treatment of shock or adrenal crisis (Chapter 23)

inflammatory/ allergic
• most extensive use; palliative not curative
• rheumatoid arthritis, rheumatic fever, lupus, acute bronchial
asthma, severe & acute allergic reactions & severe allergic
dermatoses
• prednisone – most common oral corticosteroid
• topical – skin conditions
 weakest – hydrocortisone
 intermediate – triamcinolone acetonide
 most potent – betamethasone dipropionate
DH1 – PHAR/EMG

Dental
oral lesions – NOT for infectious lesions like herpes
• systemically administered for treatment of oral lesions associated
with noninfectious inflammatory diseases – lichen planus

aphthous stomatitis
• triamcinolone acetonide (Kenalog in Orabase)

temporomandibular joint (TMJ)
• also affected with arthritis – systemic; if only this joint,
intraarticular injection

oral surgery – reduce post op edema, trismus & pain
• weigh pro vs. con (surgery could increase infection)

pulp procedures – pulp capping, pulpotomy,
hypersensitive cervical dentin therapy – still
experimental
DH1 – PHAR/EMG
 steroids
suppress immune system & with
chronic use, infections more likely &
healing delayed (be careful if surgery);
because of antiinflammatory property,
symptoms may be masked
DH1 – PHAR/EMG
 GI
- steroids stimulate acid secretion – be
careful giving salicylates or NSAIAs
 BP – steroids can exacerbate
hypertension
 glaucoma – exacerbated when used with
other agents (ex. anticholinergics)
 behavioural changes – with or during
withdrawal – psychoses, euphoria or
depression
 osteoporosis – with long-term use;
fractures; tooth loss
DH1 – PHAR/EMG
 infection
– decrease ability to fight infection
 delayed wound healing
 adrenal crisis – dental phobia patient may
need adrenal steroids before stressful dental
appointment
 periodontal disease – steroids contribute to
periodontal disease
• interfere in ability to fight infection →inflammation
• osteoporosis in bones – reduces bony support for
teeth
DH1 – PHAR/EMG











• hormones secreted by endocrine glands &
are transported by the blood to target
organs
– endocrine glands: pituitary, thyroid,
parathyroids, pancreas, adrenals, gonads &
placenta
• help maintain homeostasis by regulating
body functions
• most important clinical applications:
– treatment of diabetes mellitus (insulin)
– treatment of hypothyroidism (levothyroxine)
DH1 – PHAR/EMG










pituitary gland: small endocrine gland
located at the base of the brain
a.k.a. “master gland” – regulatory effect on
other endocrine glands & organs of the
body
pituitary deficiency (hypopituitarism):
– metabolism, dwarfism, hypothyroidism,
libido, retarded dental development
hypersecretion of pituitary hormones:
– sexual precocity, goiter, acromegaly, giantism
DH1 – PHAR/EMG
ii. Hypothyroidism
thyroid function: child = cretinism
adult = myxedema
• mental & physical retardation
• oral findings in children – delayed tooth eruption,
malocclusion, chance of perio disease, poorly shaped
teeth & carious, gingiva inflamed or pale & enlarged
• abnormally sensitive to CNS depressants including
opioids & sedatives
• hypothyroid pregnant women give birth to offspring with
large teeth
• treatment of hypothyroidism: oral replacement
therapy with exogenous thyroid hormones ex.
levothyroxine (Synthroid)
DH1 – PHAR/EMG
 Two
types:
DH1 – PHAR/EMG
iii.Hyperthyroidism











• thyroid function
• diffuse toxic goiter (Graves’ disease) –
diffusely enlarged, vascular thyroid gland;
young adults; disorder of the immune system
• toxic nodular goiter (Plummer’s disease) –
nodules in thyroid gland spontaneously secrete
excessive hormone & rest of gland atrophies;
older patients
• Hashimoto’s disease – chronic inflammation
of thyroid; middle-age women; with other
autoimmune diseases
DH1 – PHAR/EMG















iii. Hyperthyroidism
• thyrotoxicosis - levels of circulating thyroid hormones
• manifestations – exophthalmos (protruding eyes) &
anxiety; CV system is hyperactive thus, epinephrine is
contraindicated (cardiac dose okay but careful);
propranolol used to counteract tachycardia
• oral manifestations – accelerated tooth eruption, loss
of alveolar process, demineralization of jawbone &
rapidly progressing periodontal destruction
• treatment (both treatments lead to hypothyroidism):
– radioactive iodine (131-I) over 21 yo’s
– thyroidectomy - surgical
• if above treatment is intolerable, then antithyroid
agents such as propylthiouracil (PTU) &
methimazole (Tapazole) are used with propranolol (b blockers)
DH1 – PHAR/EMG
2
hormones secreted by pancreas:
• insulin – promotes fuel storage (glucose
 out of blood)
• glucagon – promotes fuel metabolism
 (glucose into blood)
DH1 – PHAR/EMG
















i. Diabetes Mellitus (DM)
• abnormal carbohydrate metabolism & inappropriate
hyperglycemia
• Type I – (IDDM) Insulin Dependent Diabetes Mellitus
– people < 30 yo’s (juvenile); results from autoimmune
destruction of cells in pancreas
– complete lack of insulin secretion from pancreas; if no
insulin, DM is fatal
– treatment: insulin injections
• Type II – (NIDDM) Non-Insulin Dependent Diabetes
Mellitus
– people > 40 yo’s
– pancreas produces enough insulin to prevent ketoacidosis
but not enough to normalize plasma glucose
– treatment: first with diet & exercise, then with orally acting agents & if all this fails, insulin
• Type III – Drug Induced
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Complications of Diabetes
• uncontrolled diabetes produces susceptibility to dental
caries due to xerostomia
• DM can affect dental development of children – differ
at which they lose deciduous teeth & gain permanent
teeth
• periodontal disease – more prone to getting it
• dental appt’s should not interfere with meals & minimal
stress; oral surgery appt’s – 1.5 – 2 hours after breakfast
& medication taken – also watch delayed wound
healing/infections because of fragile blood vessels;
scaling & root planing okay
• cautions: drugs that insulin release & insulin
requirement such as epinephrine, glucocorticoids or
opioid analgesics should be used with caution unless DM is in GOOD control.
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Systemic Complications of Diabetes
• CV - incidence of CV problems
• retinopathy – DM is major cause of blindness
in adults
• neuropathy - or absent feelings, especially in
lower extremities; also, pain & discomfort
related to tongue & other oral structures
• infections – gangrene can occur in peripheral
extremities, especially feet & legs
• healing - slower
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The Dental Patient with Diabetes:
•
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ask questions like “When did you last test your
blood sugar,” & “What were the results?”
2 lab tests useful to evaluate patient’s glucose
control:

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
– serum glucose - measure of glucose at the time that
blood is sampled
not a good reflection on patient’s OVERALL glucose control

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– glycosylated hemoglobin (HbA1c) – reflects
glucose control over a 2-3 month period
more accurately reflects patient’s OVERALL glucose control
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Treatment of Hypoglycemia:
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• if awake: fruit juice, cake icing, glucose gel etc.
• if unconscious (& lacks swallowing reflex):
intravenous dextrose (50%)
• have these in dental office in case of
emergency
• clinically difficult to distinguish between hypo- &
hyperglycemia so give sugar anyways (it won’t
do any additional damage to hyperglycemics &
dental office is not equipped to treat
hyperglycemia anyways); if hypo- then sugar
will help; if hyper- sugar will NOT help & patient
needs to be taken to emergency
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Drugs Used to Manage Diabetes
There are 2 ways of managing diabetes with
drugs:
1. insulins
2. oral antidiabetic agents
a) sulfonylureas > oral hypoglycemic agents
b) biguanides >
c) -Glucosidase inhibitors > antihyperglycemics
d) thiazolidinediones >
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2 major female sex hormones
i. estrogens
ii. progestins
 secreted by ovaries, testes & placenta
 responsible for producing female sex
 characteristics, developing the
 reproductive system, & preparing the
 reproductive system for conception
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i. Estrogens
role in female sexual cycle & puberty changes
in girls; promote growth & development of
vagina, uterus, fallopian tubes, breasts, &
axillary and pubic hair
present in oral contraceptives (OCs), used to
treat menstrual disturbances, osteoporosis,
hirsutism, cancer & symptoms of menopause
estradiaol transdermal system (Estraderm)
used to treat symptoms of menopause
2 tablets of norgestrel (Ovral) given as
“morning-after” pill
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i. Estrogens
adverse reactions: nausea & vomiting
(tolerance develops with continued use),
edema, weight gain, hypertension, endometrial
carcinoma in postmenopausal women
(cancelled out by giving progestin –
medroxyprogesterone (Provera) in last 10 days
of cycle)
oral adverse effects: puberty gingivitis,
pregnancy gingivitis & chronic desquamative
gingivitis
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ii. Progestins
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primary use: in almost all oral contraception
combinations
secondary use: medroxyprogesterone (Provera) used
orally by postmenopausal women (with estrogens as
well) – prevents uterine cancer; women with
hysterectomies do not need Provera with estrogen use
progesterone promotes secretory changes in
endometrium & prepares uterus for implantation of
fertilized ovum
– if implantation does not occur, progesterone & menstruation
begins
– if implantation occurs, maintenance of progesterone &
estrogen levels occurs thus preventing menstruation
ntrauterine devices (IUD) has progesterone agent
levonorgestrel (Norplant) – implanted under skin of arm –
provides contraception for at least 5 years
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iii.Oral Contraceptives (OCs)
consist of estrogens & progestins in various
combinations; 99% effective (if patient
compliance is perfect)
interfere with fertility by inhibiting FSH & LH &
therefore preventing ovulation
also interfere with impregnation by altering
endometrium & secretions of cervix
adverse effects: thrombophlebitis,
thromboembolism & carcinogenicity
oral adverse effects: gingival fluid & gingivitis
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iii.Oral Contraceptives (OCs)
 contraindications: thromboembolic disorders,
 significant liver dysfunction, known or
 suspected carcinoma of breast or other
 estrogen-dependent neoplasm, & undiagnosed
 genital bleeding
 antibiotics: certain Ab have said to reduce the
 effectiveness of OCs (incidence is rare) but
 additional method of contraception suggested
 during antibiotic period of use
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Antineoplastic Agents:
 designed to treat malignancies
 New use: management of diseases with
inflammatory component such as,
psoriasis, rheumatoid arthritis & systemic
lupus erythematosus
 prescribed by oncologists,
rheumatologists & oral pathologists
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many human carcinogens are environmental ex.,
polychlorinated biphenyls (PCBs)
other known carcinogens: second-hand tobacco smoke,
aflatoxins (produced by moldy peanuts), sunlight (↑ in
malignant melanoma & squamous cell carcinoma), and
benzene
patients with hepatitis have ↑ incidence of liver cancer
than normal patients
normal cells have mechanism to turn off cell growth
under certain signals but with cancer, change in the
cell occurs so that they continue to grow (thus,
abnormal neoplastic cells continue to grow)
cells can migrate to distant sites and metastases form
colonies; ex. cancer that begins at breast may spread to
bone or liver
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
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a.k.a. cancer chemotherapeutic agents
used clinically to interfere with neoplastic cells
suppress growth of cells & attempt to destroy & prevent
spread of malignant cells
used alone or in combination with radiation or surgery
depending on malignancy
cancers that are insensitive to antineoplastic agents are
treated with radiation and/or surgery
current philosophy for use of antineoplastic agents
involves treating the initial stages of disease very
aggressively therefore, ↑ chance of controlling & curing
the disease BUT many severe side effects
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 efficacy
of antineoplastic agents based on their
ability to interfere with the metabolism or
reproductive cycle of the tumor cells, thereby
destroying them
 most antineoplastic drugs labeled as being
either:
• cell-cycle specific: effective only at specific phases of
cellular growth
• cell-cycle nonspecific: effective at all levels of the
cycle (resting & proliferating cells)
 resistance
to chemotherapy occurs by:
• de novo resistance: the neoplasm was always resistant
to the chemotherapeutic agents
• acquired resistance: occurs through natural selection
or mutation
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
antineoplastic agents divided into groups
depending on their mechanism of action
1. alkylating agents – react with DNA in all cycles
of cell, preventing reproduction
2. antimetabolites – attack the cells in the S
period (DNA synthesis); more effective on
rapidly proliferating neoplasms
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3. antibiotics – cell-cycle nonspecific; effective on solid
tumors
4. hormones
a. prednisone – used to suppress lymphocytes in
leukemias & lymphomas & in combination therapies
b. estrogens – used for palliation in inoperable breast
cancer
- Tamoxifen, an antiestrogenic substance used to manage
breast cancer and recently been shown to prevent breast
cancer in high-risk women
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 rapidly
growing cells like neoplastic cells are
more susceptible to inhibition or destruction by
antineoplastic agents but most serious
difficulty encountered from this therapy stems
from the lack of selectivity between tumor &
normal cells
 therefore, certain normal cells also destroyed
during therapy, resulting in adverse effects
 cells of the GI, bone marrow and hair follicles
are faster growing normal cells, therefore, early
side effects are associated with these tissues
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Principle Adverse Effects:
 dermatologic: vary from mild erythema to
exfoliative dermatitis & Stevens-Johnson
syndrome; alopecia frequent with re-growth
when therapy discontinued
 hepatotoxicity: predominantly with
antimetabolites ex. methotrexate (Amethopterin)
 neurologic: peripheral neuropathy, &
convulsions been associated primarily with the
plant alkaloids vincristine (Oncovin) &
vinblastine (Velban)
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Principle Adverse Effects:
immunosuppression: antineoplastic agents suppress
the immune system therefore, enhanced susceptibility
to infection or second malignancy can occur after
treatment
germ cells: inhibition of spermatogenesis and
oogenesis is frequent, temporarily; mutations within
germ cell can occur; menstrual cycle may be inhibited;
recovery occurs after discontinuation
oral effects: discomfort, sensitivity of teeth & gums,
mucosal pain & ulceration, gingival hemorrhage,
dryness, and impaired taste sensation; inflammation of
the mouth, xerostomia, or glossitis (DO NOT
recommend any products containing alcohol – drying
effect); infection from leukopenia & bleeding from
thrombocytopenia can occur
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 optimize
oral health
 procedures should be planned to
coincide with the presence of the highest
level of formed blood elements – that
would be either just before treatment or
first few days of treatment (lag time)
 avoid treatment just after drug therapy –
white blood cell count too low
(agranulocytosis) and infection risk
higher; also, platelets too low (thrombocyto-penia) – bleeding can occur
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Administered via IV or Oral route
Absorbed rapidly by bone tissue (IV)
Excreted by the kidney (IV)
Used by cancer patients, and also to treat osteoporosis.
These drugs inhibit osteoclast action, and the
resorption of bone.
Bisphosphonates were developed in the 19th century,
but were first investigated in the 1960s for use in
disorders of bone metabolism. Their non-medical use
included water softening in irrigation systems used in
orange groves. The initial rationale for their use in
humans was their potential in preventing the
dissolution of hydroxylapatite, the principal bone
mineral, and hence arresting bone loss. Only in the
1990s was their actual mechanism of action
demonstrated.
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Osteonecrosis
 Is
or Avascular necrosis:
a disease resulting from the temporary or
permanent loss of blood supply to the bones.
Without blood the bone dies and causes the bone
to collapse. If the process involves the bone near a
joint it often leads to the collapse of the joint
surface.
 Eg. TMJ, Knee, Hip
 Difficulty healing and repair of bone.
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 Osteonecrosis
of the jaw bone is a recently
recognized adverse effect of the
bisphosphonates.
 About 94% of all cases of osteonecrosis
have been reported in cancer patients
receiving IV bisphosphonates.
 Severe bone disease that affects the
maxilla and the mandible.
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 Osteonecrosis
of the jaw, in most cases
have been reported after tooth extraction
and other dental procedures that
traumatize the jaw.
 Very difficult to treat once it occurs.
 Therefore; very important for the hygienist
to ask patient if they are taking or
receiving a bisphosphonate drug.
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 Maintenance, oral
health exams and other
dental procedures should be preformed
before starting bisphosphonates, or within
3 months of beginning therapy.
 Drug-free periods are not recommended
with this drug, therefore client should not
be asked to stop taking for dental
procedures, because the drug stays in the
bone for years.
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 The
practice of good oral hygiene can
decrease a clients chances of developing
osteonecrosis.
 Chlorhexidine rinses, systemic antibiotics,
and analgesics should be used if clinically
necessary.
Respiratory & Gastrointestinal
Drugs
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
Respiratory Diseases
noninfectious respiratory diseases:
Asthma
ii. Chronic Obstructive Pulmonary Disease
(COPD)
i.
a. chronic bronchitis
b. emphysema
iii. Other – upper respiratory tract infections
such as viral or bacterial
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Respiratory Diseases
i. Asthma
reversible airway obstruction with inflammation (a
few hours later); reduction in expiratory airflow
when asthma treated, both components must be
addressed
precipitated by allergens, pollution, exercise, stress or
URTIs
status asthmaticus: persistent life-threatening
bronchospasm despite drug therapy
minimize stress in dental office; signs of asthma attack
– SOB & wheezing
patients should bring fast-acting β2-agonist inhalers
for prophylactic use or in management of an acute
asthmatic attack
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Respiratory Diseases
ii.
COPD
irreversible airway obstruction; smoking is associated
with almost all COPD; ↑bronchospasm
anticholinergics (1st line treatment) & β-adrenergic
agonists used to produce bronchodilation for both
conditions of COPD
a. Chronic Bronchitis
•
•
result of chronic inflammation of airways & excessive sputum
production
b. Emphysema
alveolar destruction with airspace enlargement and airway
collapse
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
Respiratory Diseases
iii. Other (URTIs)
medications include adrenergic agonists
for nasal congestion or
bronchoconstriction, antihistamines to
reduce secretions, expectorants to thin
sputum & antitussives to control coughing
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Drugs Used to Treat Respiratory Diseases
i. Sympathomimetic Agents
 produce bronchodilation by stimulation of
β-receptors in the lungs
 selective β2-agonists used orally, by
inhalation, and parenterally are the
mainstay of respiratory therapy
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Drugs Used to Treat Respiratory Diseases
i. Sympathomimetic Agents
a. Nonselective (Nonspecific) β-adrenergic
Agonists
 epinephrine & isoproterenol produce
bronchodilation
 parenteral epinephrine still used to treat
acute asthmatic attack
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Drugs Used to Treat Respiratory Diseases
i. Sympathomimetic Agents
b. Selective (Specific) β2-Agonists
have specificity for the respiratory tree
first line of treatment for mild occasional asthma
drugs of choice for emergency treatment of acute
attack of asthma
less side effects than epinephrine
albuterol (Ventolin) administered by inhalation or
orally (tablet or liquid)
take albuterol AND a steroid inhaler (to prevent
inflammation) – a commonly occurring oversight
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
Drugs Used to Treat Respiratory Diseases
ii. Metered-Dose Inhalers (MDI)
advantages:
•
•
•
•
•
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delivers medication directly into bronchioles (side effects &
total dose low)
bronchodilator effect greater than oral
inhaled dose can be accurately measured
onset of action rapid & predictable
MDIs compact, portable, sterile
disadvantages:
•
•
•
difficult to use properly (esp. in children)
can be abused
examples of medications in MDI form: corticosteroids &
specific & nonspecific β-agonists
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Drugs Used to Treat Respiratory Diseases
iii. Corticosteroids
reduce inflammation that occurs a few hours after an asthma
attack; hasten recovery & reduce hyperreactive airway
typical side effects associated with corticosteroid therapy do not
occur with topical aerosol administration
examples: beclomethasone (Beclovent) & fluticasone (Flovent)
patients have significant improvement in pulmonary function
with decrease in wheezing, tightness, and cough
chronic oral corticosteroids, i.e. prednisone used in severe cases
candidiasis can occur from chronic use of inhalation
corticosteroid; rinse mouth & gargle with water after inhaler use
also available in nasal spray for stuffiness & ↓inflammation:
beclomethasone (Beconase)
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Drugs Used to Treat Respiratory Diseases
vii. Agents Used to Manage URTIs
a. Nasal Decongestants
OTC β-adrenergic agonists that constrict blood
vessels of nasal mucous membranes
chronic, topical use may result in rebound
swelling & congestion; do not use decongestant
nose spray for more than a few days
example: pseudoephedrine (Sudafed, Sucrets)
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Drugs Used to Treat Respiratory Diseases
vii. Agents Used to Manage URTIs
b. Expectorants & Mucolytics
promote removal of exudate or mucous from
respiratory passages
example: OTC guai-fene-sin used alone (ex.
Robitussin) or mixed with antitussive agent
(Robitussin DM) expectorant
mucolytics – enzymes able to digest mucous
example: acetyl-cys-teine (Mucomyst) used to
loosen secretions in pulmonary diseases such
as cystic fibrosis
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Drugs Used to Treat Respiratory Diseases
vii. Agents Used to Manage URTIs
c. Antitussives
may be opioids or related agents used for
symptomatic relief of nonproductive cough
opioids more effective but have addicting
properties
codeine-containing cough preparations are
common
example: dexatro-meth-orphan (the DM in
Robitussin) suppresses the cough reflex; no
histamine release
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Dental Implications of the Respiratory
Drugs
 with severe COPD, a patient can develop
pulmonary hypertension, increasing risk
for cardiac arrhythmias
 stress should be minimized
 avoid aspirin; erythromycin may alter
metabolism of theophylline
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
GI disease:
i. Gastroesophageal Reflux Disease (GERD)
ii. Ulcers
Gastroesophageal Reflux Disease (GERD)
a.k.a heartburn; most prevalent; complaints of
burping, cramps, flatulence, fullness & congestion in
the stomach
stomach contents, including acid, reflux back through
the cardiac sphincter into the esophagus
pain may be severe & in middle of chest – may
confuse with heart attack
main problem: inadequate function of the cardiac
sphincter
treatment in 2 ways:
i.
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•
•
↓ acid in stomach (with H2-blockers & proton pump
inhibitors)
constrict or toning cardiac sphincter – with gastrointestinal
stimulants
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Ulcers
may occur in stomach or small intestine
not by “too much acid”
related to Helicobacter pylori organism
treated by combination of one or more
antibiotics and an H2-blocker or a proton pump
inhibitor (reduce acid in stomach)
some ulcers are secondary to chronic use of
NSAIAs – treat with prostaglandin Misoprostol
(Cytotec)This medication can replenish prostaglandin
ii.
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in the stomach lining. Prostaglandin has a protective
effect in the stomach lining against acid.
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Drugs Used to Treat GI Diseases
i.
Histamine2-Blocking Agents
block nocturnal gastric acid secretions and inhibit gastric acid
secretion stimulated by other agents such as food & caffeine
example: cimetidine (Tagamet); with meals and at bedtime
uses: indicated for treatment of ulcers & management of
symptoms of ulcers & GERD
encourage smoking cessation to patient since smoking ↑’s acid
production and ↓’s effect of H2-blockers
adverse reactions: antiandrogenic effects – gynecomastia,
reduction in sperm count, impotence
•

if this occurs, change from cimetidine to ranitidine (Zantac) or
famotidine (Pepcid)
dental drug interactions:
•
•
alcohol – blood alcohol levels may be higher with this medication
benzodiazepines – slower metabolism
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Drugs Used to Treat GI Diseases
ii. Proton Pump Inhibitors (PPI)
example: omeprazole (Prilosec)
potent inhibitor of gastric acid secretions
effective (with antibiotics) in healing both gastric &
duodenal ulcers; treat & maintain GERD
iii. Mixed Antiinfective Therapy for Ulcers
to treat ulcers, a combination of 2 or 3 antiinfective
agents (tetracycline, metronidazole, or amoxicillin); an
acid reducer; an H2-blocker or a PPI and bismuth
subsalicylate (Pepto-Bismol) may be used
newer combinations – one antibiotic (clarithromycin)
& a PPI (omeprazole)
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Drugs Used to Treat GI Diseases
iv. Antacids
drugs that partially neutralize hydrochloric
acid in the stomach
treatment for:
•
•

acute gastritis – most common; a.k.a. “heartburn”
or “upset stomach” – burning feeling
symptoms of ulcers
classified as:
•
•
systemic – sodium bicarbonate – rapidly
neutralizes gastric acid; disadvantage: alkalosis
can occur; sodium – contraindicated for CV
patients
nonsystemic - preferred
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a.
b.
c.
d.
Drugs Used to Treat GI Diseases
v.
Miscellaneous GI Drugs
mi-so-pro-stol (Cytotec) – indicated in management
of NSAIA-induced ulcers; FDA pregnancy category X
– stimulates uterine contractions
su-cral-fate (Carafate) – used to treat duodenal
ulcers; “bandage” for ulcers; inhibits the absorption of
tetracycline
meto-clo-pra-mide (Reglan) – indicated for relief of
symptoms associated with diabetic gastric stasis;
increases tone of lower esophageal sphincter
si-meth-icone (Mylicon, Gas-X) – used to relieve
flatulence (gas)
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a.
Laxatives
•
•
•
overuse, habituation, abuse in bulimic patients can occur
indicated for short-term use for constipation & use before
diagnostic procedures (ex. barium enema)
types:

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
b.
Drugs Used to Treat GI Diseases
vi.
Laxatives & Antidiarrheals
bulk – safest; increase intake of fiber or bulk laxatives in patients
with constipation
stool softeners (emollients) – dioctyl sodium sulfosuccinate, wets
& softens stool by accumulating water in the intestine
osmotic (saline) – magnesium sulfate or phosphate – holds water
osmotically
Antidiarrheals
•
•
•
used to minimize fluid electrolyte imbalances; can be either
adsorbent-like or opioid-like in action
adsorbent – kaolin & pectin (Kaopectate)
opioid-like – loper-amide (OTC Imodium) – most effective AD
agents
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Drugs Used to Treat GI Diseases
vii. Emetics & Antiemetics
Emetics – ipecac is an emetic used to treat
persons who have ingested an overdose of
drugs that could be harmful; abused by
individuals with bulimia
Antiemetics – vomiting may occur because of
a variety of situations such as motion sickness,
pregnancy, drugs, infections or radiation
therapy
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a.
b.
c.
Drugs Used to Treat GI Diseases
vii. Emetics & Antiemetics
phenothiazines – used to control severe nausea; prometh-azine (Phenergan) used in dentistry to treat
nausea & vomiting associated with surgery &
anaesthesia
anticholinergics – used for nausea & vomiting
associated with motion sickness; ex. scop-ola-mine
transdermal patch (Transderm-Scop) is placed
behind the ear & releases medication over a 3-day
period – used for motion sickness on ships & boats
antihistamines – diphenhydramine (Benadryl) an
antihistamine with antiemetic properties;
hydroxyzine (Atarax) – used in dentistry as an
antiemetic or antianxiety agent
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d.
e.
f.
Drugs Used to Treat GI Diseases
vii. Emetics & Antiemetics
meto-clo-pramide (Reglan) – controls nausea &
vomiting of patients receiving cancer
chemotherapeutic agents
benz-quin-amide (Emete-Con) - used to nausea
associated with anaesthesia during surgery
canna-bin-oids – dronabinol (Marinol) & nabilone
(Cesamet) are psychoactive substances derived from
Cannabis sativa L. (marijuana); produce effects similar
to marijuana; indicated to treat the nausea & vomiting
associated with cancer chemotherapy in patients who
have failed to respond to conventional antiemetic
therapy
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Agents Used to Manage Chronic Inflammatory
Bowel Disease (IBD)
sulf-asa-la-zine (an antibacterial agent) used to
manage IBD; corticosteroids (for inflammation) also
used but watch out for side effects; immune
modulators such as cyclosporin reduce inflammation
IBD divided into:
viii.


a.
•
•
•
b.
•
•
Ulcerative Colitis
autoimmune response
only mucosal wall of intestinal tract
involves rectum and maybe distal part of colon
Crohn’s Disease
all layers of intestinal wall
can involve whole intestine BUT colon is most commonly
affected
Pregnancy & Breast Feeding
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 pregnant
women often need additional dental
treatment during their pregnancies, and, in
addition, that treatment must be carefully
planned
 no unnecessary drug should be administered to
the pregnant woman
 if drug needed, the risk to the fetus must be
weighed against the benefit to the woman
 check med history and if patient is pregnant
(from ages 11 to 63)
DH1 – PHAR/EMG

two main concerns must be addressed
when considering whether to give a drug
to a pregnant woman
1. is the drug teratogenic ?
2. drug can affect the near-term fetus, causing the
newborn infant to have an adverse reaction,
such as respiratory depression or jaundice
DH1 – PHAR/EMG
Pregnancy Trimesters
involves 3 trimesters (3 months long)
i.

•
•
•
1st – organs in fetus are forming; most critical time
for teratogenicity; if abnormalities occur very early
in development, spontaneous abortion; dental
prophylaxis (cleaning) with detailed oral hygiene
instructions (OHI) and visual exam WITHOUT xrays;
if nauseated, avoid treatment
2nd – OHI and another dental prophylaxis, if needed;
patient most comfortable at this time
3rd – closest to delivery; patient more uncomfortable;
difficulty lying prone – sit or with right hip elevated;
drugs that may affect the newborn child should not
be given in this trimester
DH1 – PHAR/EMG
Teratogenicity
very difficult to prove that a drug is teratogenic
examples:
ii.


•
•
•
•
•
•
•
•
thalidomide
some antineoplastic agents
warfarin
lithium
some antiepileptic agents (phenytoin)
the tetracyclines
certain steroids (androgens)
ethyl alcohol
DH1 – PHAR/EMG
Food & Drug Administration (FDA)
Pregnancy Categories
drug categories A, B, C, D & X
category A is safest
category X should NOT be used on
pregnant women
iii.



DH1 – PHAR/EMG






Nursing is becoming more popular
consider risk-to-benefit ratio before administering drugs
drugs without strong indications for use should not be
taken
almost ALL drugs given to the nursing mother can pass
into the breast milk in varying concentrations
for a few drugs, nursing is clearly contraindicated; if
must, then discontinue nursing or milk expressed &
discarded until meds finished
for non-contraindicated drugs, timing of nursing can
further reduce the dose to which the infant is exposed
DH1 – PHAR/EMG
 in
general, a drug should be used in a pregnant
woman ONLY IF the benefits to the pregnant
woman outweigh the risks to the fetus and a
definite indication exists
DH1 – PHAR/EMG
 dental
health care workers can be involved
with drug abuse (both legal & illegal
drugs) in a variety of ways
• patients seen in the dental office may be abusing
drugs
• “potential” patients – call office in pain; request
prescription
• employees may abuse drugs
• friends & relatives may abuse drugs
DH1 – PHAR/EMG
 alcohol
& tobacco are 2 drugs whose abuse
causes more medical problems than all other
drugs of abuse combined
 half the hospital beds in the U.S. would be empty
if no one used tobacco & drank alcohol
 agents used for their psychoactive properties
can be divided into those that have therapeutic
value (opioids & sedative hypnotics) & those that
have no proven therapeutic value (psychedelics)
 prevention is the key and it starts with education
DH1 – PHAR/EMG
 abuse
of a drug is defined as the use of a
drug for nonmedical purposes, almost
always for altering consciousness
 whether a drug has an abuse potential is
determined by its pharmacologic effect
 misuse of a drug means using the drug in
the wrong dose or for a longer period than
prescribed
DH1 – PHAR/EMG
Psychologic Dependence
 a state of mind in which a person believes that he
or she is unable to maintain optimum
performance without having taken a drug
 can vary in severity from mild desire (ex.
morning cup of coffee) to compulsive obsession
(ex. next dose of cocaine)
Physical Dependence
 altered physiologic state that results from
constantly increasing drug concentrations
DH1 – PHAR/EMG
Tolerance
 the need to increase the dose continually in
order to achieve the desired effect or the giving
of the same dose, which produces a diminishing
effect
 in terminal patients, this tolerance requires everincreasing doses of opioids even if the pain
remains constant
 the doses reached over time with the terminally
ill would be fatal to a patient without tolerance
DH1 – PHAR/EMG
Addiction, Habituation & Dependence
 in both addiction & habituation the desire
to continue using the drug is present, but
in addiction, dependence is also present
 these terms should be replaced by the
term dependence – a state of psychologic
or physical desire to use a drug
DH1 – PHAR/EMG
to treat abuse, a multifactorial
approach is needed: counseling,
education, self-help groups, and an
intense desire to stop
abusable drugs divided into following
groups:


I.
II.
III.
Central Nervous System (CNS) depressants
(“downers”)
CNS stimulants (“uppers”)
Hallucinogens
DH1 – PHAR/EMG
Ethyl Alcohol (Ethanol)
a sedative agent used socially
because its legal, availability makes it the most
frequently abused drug (called alcoholism)
rapidly & completely absorbed from the GI tract
excreted by lungs (alcohol breath) & urine
acute intoxication:
i.





•
•
•
mild – impairment of judgment, emotional problems &
nystagmus can occur
moderate – dilated pupils, slurred speech, ataxia & staggering
gait
severe – seizures, coma & death
DH1 – PHAR/EMG
Ethyl Alcohol (Ethanol)
withdrawal – occurs after the use of alcohol; the
more alcohol consumed & the more time spent
consuming, the more violent the withdrawal
syndrome; a benzodiazepine (ex. chlordiazepoxide)
may be used to prevent withdrawal symptoms;
withdrawal can be life-threatening if not properly
treated
chronic effects – impotence, gastritis, arrhythmias
and hypertension can occur; if pregnant woman
using alcohol – fetal alcohol syndrome can occur –
retarded body growth, small head (microencephaly),
poor coordination, underdeveloped midface & joint
anomalies; severe cases – cardiac abnormalities &
mental retardation; chronic use - ↑risk of cancer of
mouth, pharynx, larynx, esophagus & liver; tobacco
use increases the risk even more
i.


DH1 – PHAR/EMG
Ethyl Alcohol (Ethanol)
alcoholism – a disease in which the alcoholic
continues to drink despite the knowledge that
drinking is producing a variety of problems; there is
a genetic link; “red flags” for alcohol abuse –
drinking early in a.m.; shaking when not drinking,
blackouts, being told you drink too much, missing
work & problems in personal relationships
treatment – Alcoholics Anonymous is most
successful; drug treatment – older alcoholics that are
motivated & socially stable given disulfiram
(Antabuse) – DO NOT TAKE WITH ALCOHOL or
vasodilation, flushing, tachycardia, dyspnea,
throbbing headache, vomiting & thirst can occur;
drugs like metronidazole also produce these
reactions (minor version) if taken with alcohol
i.


DH1 – PHAR/EMG
Ethyl Alcohol (Ethanol)
dental treatment of the alcoholic patient –
all health care workers have responsibility to
identify & assist patients in obtaining
treatment; most alcoholics have poor oral
hygiene because of neglect; check for sweet
musty breath & painless bilateral
hypertrophy of parotid glands characteristic
of alcoholism; cirrhosis can occur –
impairment of liver can cause bleeding
tendencies (↓vitamin K storage);
spontaneous gingival bleeding; later in liver
failure – abdomen becomes distended with
fluid
i.

DH1 – PHAR/EMG
Ethyl Alcohol (Ethanol)
dental considerations – complications of
alcoholism include glossitis, loss of tongue
papillae, angular/labial cheilosis & candida
infections; alcoholism & tobacco abuse can
cause oral squamous cell carcinoma – check
any oral lesions carefully (look for
leukoplakia or ulcerations especially around
lateral borders of tongue or floor of mouth);
smell patients breath, palpate parotid glands,
expect poor oral hygiene & evaluate
bleeding tendencies (important for surgical
procedures)
i.

DH1 – PHAR/EMG
Nitrous Oxide
an incomplete general anaesthetic readily available in many
dental offices
primarily abused by dental personnel & food service
employees; typical user a 40-year-old white male who has often
abused illicit drugs
abuse results in psychologic but not physiologic abuse
inhalation of 50 – 75% N2O produces “high” for 30 seconds
followed by sense of euphoria for 2 – 3 minutes; tingling or
warmth of face, auditory illusions, slurred speech & stumbling
gait can occur
adverse reactions – dizziness, headache, tachycardia, syncope,
& hypotension, hallucinations; cannot drive or operate heavy
machinery; with chronic use – can produce mental dysfunction
& infertility; 100% nitrous oxide – nausea, cyanosis & falling can
occur, can produce hypoxia that results in death
ii.





DH1 – PHAR/EMG
Opioid Analgesics
examples of abused drugs:
iii.

heroin * most commonly administered parenterally
•

•
•
•
•
•
•


acute overdose signs & symptoms – pinpoint pupils, depressed
respiration, hypotension & shock, slow or absent reflexes,
drowsiness & coma
methadone (Dolophine)
morphine
hydromorphone (Dilaudid)
meperidine (Demerol)
oxycodone (Percodan)
pentazocine (Talwin)
opioids elevate user’s mood, causes euphoria,
relieve fear & apprehension, produce feelings of
peace & tranquility, suppress hunger & reduce
sexual desire
addict can resort to criminal activity & violence to
support drug habit
DH1 – PHAR/EMG
Opioid Analgesics
management of acute overdose &
withdrawal – if triad of narcotic overdose
present (respiratory depression, pinpoint
pupils & coma), naloxone (Narcan) can be
given – if no response, unlikely that
respiratory depression caused by opioid
overdose; patients in withdrawal made
comfortable with methadone (long-acting
opioid that can replace heroin & then
gradually be weaned off)
iii.

DH1 – PHAR/EMG
Opioid Analgesics
dental considerations for opioid abuser:
iii.

•
•
•
•
pain control – tolerance develops in abuser; alleviate cause of
pain first then give NSAIAs for analgesia
prescription for opioids – watch out for “shoppers”
increased incidence of disease – needles can increase
diseases such as hepatitis B, HIV, AIDS & sexually transmitted
diseases; infections caused by nonsterile needles & solutions
can produce osteomyelitis, and abscesses in kidneys & heart
valves – tricuspid valve (use prophylactic Abs before dental
treatment
chronic pain – opioids not effective in relief of chronic pain so
be careful! Do not get blackmailed into prescription just
because pain may be related to your work
DH1 – PHAR/EMG
examples:

•
•
•
•
•


iv.
Sedative-Hypnotics
barbiturates
alcohol
meprobamate (Miltown)
benzodiazepines – ex. chlordiazepoxide (Librium) & diazepam
(Valium)
nitrous oxide
initial symptoms of abuse resemble alcohol
intoxication – euphoria, poor memory & judgment,
slurred speech & ataxia
with increasing doses, drowsiness, sleep, depressed
respiration, decreased cardiac output, decreased GI
activity & urine output
DH1 – PHAR/EMG
Sedative-Hypnotics
generally taken orally, often combined with other drugs of
abuse
with acute overdose, respiratory & cardiovascular depression
can occur leading to coma & hypotension
with prolonged misuse, emotional instability, hostile & paranoid
ideations and suicidal tendencies are common
also used to administer to others to control them – ex. “roofies”
– short-acting benzodiazepine flunitrazepam – used as a daterape drug; difficulty recounting & remembering events
management of acute overdose & withdrawal – support the CV
and respiratory systems; establish & maintain airway; gastric
lavage after intubation & dialysis to assist in removal of some
drugs; withdrawal – can be life-threatening and patient should
be hospitalized; treatment of withdrawal:
iv.





•
•
replacement of the abused drug with an equivalent drug (ex.
Chlor-diaze-poxide or diazepam)
gradual withdrawal of the equivalent drug
DH1 – PHAR/EMG
Cocaine
a CNS stimulant with L.A. properties when applied
topically
used by “sniffing” or “snorting” or IV injection
recent variant is a free-base form (VERY potent) –
smoked & goes by “crack” or “rock”
intense euphoria & sense of total self-confidence
created by cocaine, feeling of paranoia & extreme
excitability can cause violent acts to be performed
psychologic dependence becomes intense but
neither tolerance or withdrawal has been shown
medical use – in nasal canal, used on mucous
membranes to produce L.A. and vasoconstriction to
reduce hemorrhage
no appropriate dental use
i.







DH1 – PHAR/EMG
examples:

•
•
•






ii.
Amphetamines
Meth-amphetamine (Desoxyn)
Dextro-amphetamine (Dexedrine)
Methyl-phen-idate (Ritalin)
use is spreading because “meth” has longer duration
of action than cocaine
produce euphoric mood, a sense of increased energy
& alertness, a feeling of omnipotence & selfconfidence
taken orally, parenterally, intranasally or inhalation
(smoking)
toxic symptoms: anxiety, aggressiveness,
hallucinations & paranoia; signs & symptoms: dilated
pupils, ↑BP, rapid pulse, arrhythmias
oral adverse reactions: xerostomia & bruxism
treatment is symptomatic – for ↑BP etc.
DH1 – PHAR/EMG
iii.





Caffeine
most widely used social drug in the world –
contained in coffee, tea, cola drinks & other
drinks
stimulants
caffeine 207toxicity can occur with as little as
300 mg (2-3 cups of coffee)
with 5 or more cups, physical dependence
can occur
withdrawal symptoms can occur at 24 hours
after the last cup of coffee; headache,
lethargy, irritability, and anxiety; tolerance
develops to these effects
DH1 – PHAR/EMG
Tobacco
the CNS-active component of tobacco is nicotine
other agents in smoking tobacco include carbon
monoxide, nitrogen oxides etc.
~25% of adult Americans smoke; children commonly
start smoking between 11- 14 years of age
smokers claim increased alertness, muscle relaxation,
facilitation of concentration & memory, and decreases
in appetite & irritability
nicotine produces ↑BP and pulse rate
chronic use can cause serious diseases such as
coronary artery disease & oral & lung cancers
iv.






DH1 – PHAR/EMG
Tobacco
smokeless tobacco – a.k.a. “chewing tobacco; oral mucosal
changes include chronic gingivitis, leukoplakia, &
precancerous lesions – perform thorough oral exam & educate
withdrawal – symptoms include anxiety, irritability, difficulty
concentrating, cravings for cigarettes, drowsiness, headaches,
increased appetite & sleep disturbances
symptoms of withdrawal can be suppressed to some extent by
administration of nicotine chewing gum (Nicorette) or nicotine
patches (Nicoderm, Habitrol)
these products reduce irritability & difficulty in concentration
but not as effective in controlling insomnia, hunger, or cravings
for cigarettes; dentally, chewing gum Nicorette can dislodge
fillings
also available in a nasal spray (Nicotrol NS)
bupropion (Wellbutrin, Zyban), an antidepressant can help
reduce cravings
dental health care worker should point out oral manifestations,
educate and offer help in smoking cessation
iv.







DH1 – PHAR/EMG
 capable
of inducing states of altered
perception & generally have no medical
therapeutic use
 all sensory input perceived with heightened
awareness (sounds are brighter & clearer,
colors are more brilliant & taste, smell & touch
are more acute
 psychologic dependence & tolerance develops
 prolonged use – long-lasting mental
disturbances varying from panic reactions to
depression to schizophrenic reactions
DH1 – PHAR/EMG
Lysergic Acid Diethylamide (LSD)
most potent hallucinogen (only
micrograms required to produce effect)
also has sympathomimetic effects like
tachycardia, ↑BP, hyperreflexia, nausea
and ↑body temperature
overdose: widely dilated pupils, flushed
face, ↑BP, hallucinations & paranoia
treatment is to provide reassurance
(“talking the user down”)
i.




DH1 – PHAR/EMG
Phencyclidine (PCP or angel dust)
originally developed as an animal
tranquilizer; very popular in the ’70’s
hypersalivation produced
users may exhibit sweating & a blank
stare & bizarre behaviour
elevation in BP, pulse rate and muscle
movement & rigidity can occur
ii.




DH1 – PHAR/EMG
Marijuana (cannabis)
derived from the hemp plant
administered orally or by inhalation (smoking)
causes increased pulse rate, bloodshot eyes &
behavioural changes
with normal doses, euphoria & enhanced
sensory perception followed by sedation &
altered consciousness (a dreamlike state)
impairs motor & mental abilities so NO
DRIVING!
iii.





DH1 – PHAR/EMG
Marijuana (cannabis)
adverse reaction: apprehensiveness, nervousness, and
panic-stricken feelings that user is losing their mind
psychologic dependence determined by frequency of
use
may produce xerostomia with higher levels of
marijuana; may develop gingivitis
heavy use – chronic bronchitis, & precancerous
changes in bronchioles
can be used for the treatment of glaucoma, and cancer
therapy related nausea (antiemetic)
iii.





DH1 – PHAR/EMG
 “shoppers” can
be identified by presence of
poor oral hygiene, long-sleeved shirts, scars
along veins, sunglasses, moodiness,
intoxicating behaviour
 this is not always the case – watch out for
excellent story-tellers/actors; look & behave
like a typical patient; may suggest a specific
drug or indicate an allergy to some drugs they
do not want
 IV users more likely to have STDs, hepatitis,
HIV +ve or AIDS, TB or altered valves
 lock and key controlled substances – shoppers
can be violent
DH1 – PHAR/EMG
 can
present a danger to their patients
 a professional abusing drugs may be in
denial, and confrontation by staff,
relatives & friends is often ineffective
 often suicide is thought of and done
 report the person to the appropriate
“impaired professional committee” for
their profession – they will assist the
person in becoming a functioning
practitioner again
Preparation and Prevention
Emergency Care
DH1 – PHAR/EMG
Attention to Prevention
to prevent an emergency, employ
proper patient assessment techniques
including thorough medical history
questionnaires, documentation of vital
signs & completion of physical
assessment of patient – extra / intraoral
examination
this will help incorporate proper risk
management & stress reduction
protocols
anticipate, be aware & be prepared
i.



DH1 – PHAR/EMG
Factors Contributing to Risk of
Medical Emergencies
older patients
taking medications – drug interactions
more complex dental procedures ↑time in chair
↑use of drugs in dentistry – ex.
antibiotics, anaesthesia pain medication,
tranquilizers
ii.




DH1 – PHAR/EMG
Assessment for Routine Treatment
first contact
parts of assessment – signs & symptoms, vital
signs, med history, documentation of intra /
extraoral findings
emergency indicators – ex. appearance
ii. Patient’s Medical History
update & document changes
use of medical alert box – including allergies &
adverse drug reactions, medications etc.
i.





DH1 – PHAR/EMG
iii.
A.

B.

C.



Vital Signs
The Eight Vital Signs
pulse, BP, respirations, temperature, height, weight,
age & Medical Alert Tag information
Baseline Vital Signs
vital signs taken at a routine appointment
During Emergency
compensating – patient experiences “fight or flight”
reaction – vital signs elevated above baseline
decompensating – vital signs fallen below baseline
shock – lack of perfusion (saturation) of oxygenated
blood to all cells of the brain & body
DH1 – PHAR/EMG
Extraoral & Intraoral Examinations
can provide findings that are clues to underlying
disease processes that predispose patient to medical
emergencies
extraoral – blood disorders & endocrine disorders
can be identified with palpitation
intraoral – lesions can indicate underlying disease
ex. diabetes, leukemia, AIDS
v. Recognition of Increased Risk Factors
allergies, drug reactions, genetic predispositions,
seizures, diabetes, etc.
vi. Comprehensive Record Keeping
iv.




DH1 – PHAR/EMG
Recognize Patient with Stress Problems
apprehension, elderly patients, essential
medications
ii. Suggestions for Effective Communication
listen to patients’ concern & fears; watch for
hyperventilation or syncope
iii. Reduction of Stress
appointment scheduling, premedication /
medication, post op follow up
i.



DH1 – PHAR/EMG


communication: telephone numbers
equipment for use in an emergency:
•
•
•
•

essential equipment
injectable drugs
noninjectable drugs
supplementary equipment – stopwatch, pen flashlight,
blanket, adhesive tape etc.
care of drugs:
• identification, record of drugs


record of emergency
practice & drills
• staff instruction, assignments, flowcharts, drills, educate new
staff members, procedures manual
DH1 – PHAR/EMG




Oxygen is the most useful drug in the
entire emergency kit
Supplied in a variety of sizes in
compressed gas cylinders
O2 administration is indicated in any
emergency situation in which
respiratory distress is evident
It is considered to be a critical
noninjectable drug