Prescription WritingMasoud Yaghmaei Chap 36 (Appendix Peterson 2008 )

Significance of Meds taken by patients in dentistryCommonly Used Meds In OMFS / dentistry

Drug Interactions

Larry j . Peterson1942 - 2002

Dental School + Medical School + HospitalDental School + Medical School + HospitalDental School + Medical School + HospitalDental School + Medical School + Hospital

Physician's DeskReference

PDR

PDR – NPD Since 1980

EXAMPLEChemical Name : 2-diethylamino-2,6- acetoxylidideGeneric Name : LidocaineTrade Name : Xylocaine , L-Caine , Dolicaine ,Octocaine , etc

Drug Nomenclature

Chemical , Generic , Trade Names

Example

Chemical Name : N-acetyl-p-aminophenol

Generic Name : Acetaminophen

Brand Name : Tylenol , Valadol , tempra ,, phenaphen , etc

Drug Nomenclature

Chemical , Generic , Trade Names

Recipe

� Prescription

� Para clinical Examinations ( Imagings & Labs )

� Referral

� Consultation

� Certification

� Recommendation letter

� Admission letter ( to Hospital )

Recipe In the Hospital

Called Orders :AdmissionPreoperativePost OperativeDischarge

Dentistry in the HospitalChap 31 Management Of The Hospitalized Patient

Any Prescriptions (meds ) ?

Any Paraclinic Examinations ?

Any Certifications ?

Limitation

Prescription Writing

Complex in the Past ( = Art )Written in :Latin & Apothecaries System Of Weights & measures

In More Recent Years, 4 Changes have greatly simplified prescription writing

� 1- proper form & dosage ( Mixing not necessary )� 2- no longer written in Latin� 3- metric system replaced the more confusing

apothecaries� 4-limit or eliminate abbreviation

Metric System

Abbreviations

Qd , bid , tid , qid

A – HeadingB – BodyC - Closing

Parts Of the Prescription

Refill 0-1,2,3

A – HeadingB – BodyC - Closing

Parts Of the Prescription

Name , degree, NP #, address , Phone Number( x2 ) of the Prescriber

patient's name , Address ,Phone , age ,date

Heading

R Symbol

Name of the drug , dosage form , then amount ( mg/ml )

Dispense = Disp ( # / No / Roman numeral )

Sig ( L. Signa, “ Write” ) = ( Label )

Body

Symbol R

L . Recipe “ You take “ Or “ take thou of “

Prescriber's SignatureDEA Number ( Drug Enforcement Administration )

Ask pharmacist for labelingRefill ( No ,1,2,3 )

Closing

Drug LegislationDEA Number ( NO , # )

Single Med

Single Recipe

Household measures

A = Heading

B = Body

C = Closing

Rx

Nystatin liquid , 100,000 U / ml

Disp , 60 ml

Sig , Swish 4 ml in mouth for 2 minutes and

then swallow q 6 h

A Few drops added to the water used for soaking acrylic prosthesis

RxClotrimazole troches 10 mg

Disp : 50 trocheSig : Let one troche dissolve in the mouth 5 times a day

Clotrimazole troche

For Candidosis

If concern is expressed about the sugar content of nystatin and clotrimazole troches , Vaginal tablets ( 100mg ) may be substituted

Acetaminophen300mg + codein 10 mg No Ten ( X )Take One by mouth q 4h Prn / Pain

1

R

09646 ( Shahid Beheshti )

82101 ( 13 Aban )

Drug Information

RxLidocaineViscous 2%Disp 30 ml bottleRinse with 1 teaspoonful for 2 minutes every 2 hours and before each meal and spit out

Topical Anesthesia

Acyclovir topical ointment 5 %

Disp :15 gm tube

Sig : Apply to the area every 2 hours during waking hours for 4 days , beginning when symptoms first occur

Topical Antiviral Agents

Secondary Herpes

Herpetic Whitlow

RxAcyclovir cap 200 mgDisp : 40 Capsules ( Or 60 )Sig : Take one Capsule q6h for 10 days ( 2Cap q8h for 10 days )

Systemic Antiviral therapy

Current FDA Recommendation is that systemic acyclovir should be used to treat oral herpes only in immunocompromised patients

RxPenicillin V tabletsDisp : 28 TabletsSig : Take One Tablet 4 times a day

Acute Odontogenic infection

RxAmoxicillin Susp 125 mg / 5mlDisp : one Bottle Sig : 5 ml PO q 6 h

Odontogenic Infection

Pediatric

Rx

1 -Penicillin V Oral Suspension 125 mg / 5 ml # one Bottle

Take 5 ml q 6 h

2 – Acetaminophen drop 100 mg / ml

take 20 drops q 4h Prn / Pain

Odontogenic Infection

Pediatric

RxPenicillin V tablets 500 mgDisp : 28 TabletsSig : Take One Tablet every 6 hours

Acute Odontogenic infection

Or q6h ( q = Every )

RxErythromycin Tablets 250 mg Disp : 40 tabletsSig : Take One Tablet q 6 h

Acute Odontogenic Infection

( Patient Allergic to Penicillin )

If nausea or stomach cramps occur , prescribe enteric – coated preparations OrA second - generation erythromycin ( eg , Clarithromycin )

Rx

Acetaminophen tablets 325 mg

Disp : Ten Sig : Take 1- 2 tablets every 4 hours as needed for pain ( Limit 4 gm /24 h)

Analgesic

Rx

Acetaminophen 300 mg with codeine 30 mg ( Tylenol # 3 )

Disp : Ten ( X )

Sig : take one tablet every 4 hours for pain

For Moderate to Severe Pain

q = EveryFor pain = As needed = Prn / pain

RxAcetaminophen tab 300 mg with codeine 10 mgDisp : Ten ( X )Sig : One Tab q 4h Prn / Pain

Acetamiphen With Codein

In IRAN

RxNystatin Plus Triamcinolone acetonide ointmentDisp : 15 gm TubeSig : Apply to affected area after each meal & at bed time

Angular Chelitis & Chelosis

Mixed Inf ( C albicans + Staph + Strep )

Predisposing Factors ( Local habits ,drooling , decreased VD ,Anemia ,

Immunosupression & Extension Of Oral Infection . CCc

Concomitant Intraoral Antifungal Treatment may be indicated

RxClotrimazole Vaginal Cream ( OTC )Disp : 1 TubeSig : Apply small dab to corner of mouth 4 times a day

Angular Chelitis & Chelosis

Rx

Sunscreen with high SPF ( greater than 15 )

Actinic Chelitis & ChelosisNormal Red Translucent Vermillion With Regular Vertical fissuring of

a smooth Surface is replaced by a white flat surface that may

exhibit periodic Ulceration

Rational for Treatment : May Progress to Malignancy

RxNystatin-Triamcinolone acetonide OintmentDisp : 15 g tubeSig : Apply to affected areas after meals and at bed time

Geographic Tongue ( BMG )

Most Assymptomatic & no tx is necessary If Symptomatic

( Secondary C Albicans Infection )

RxNystatin OintmentDisp : 15g OintmentSig : Apply to affected areas after meals and at bedtime

XerostomiaRxSodium Carboxymethyl cellulose 0/5 % aqueous solutionDisp : 120mlSig :Use as a rinse as frequently as needed

RxPilocarpine HCl Solution 1 mg / mlDisp : 100mlSig : Take 1 Teaspoonful q 6 h

Dosage should be adjusted to minimizing adverse effects ( Sweating &

Stomach Upset )

xPilocarpine Hcl tablet 5 mg Disp : 100 tabletsSig : Take One tablet q 8 h . An Extra tablet ( 10mg ) may be taken at bed time

Xero - Lube

Xerostomia� Radiation > 800 Rad

� Sjögren,s Syndrome

� Mikulicz,s disease

� Antihistamines

� Tranquilizers

� Diuretics

� Atropine-like drugs

� Women > 40

� Artificial Saliva ( Xero-lube )

Contain :

Phosphates , Chlorides & Fluoride

in addition to the Sodium

Carboxymethylcellulose

Rx

Xero – lube

Disp : 150 ml

Sig : Use as a Rinse as frequently as

needed to relieve Symptoms of

dry mouth

Post Radiation Caries

100 times > Normal Population

Rx

Fluoride gel , 1 % Sodium fluoride

Disp : 60 ml

Sig : Place 5 – 10 drops in bite guard and apply for 5 minutes four times a day

Lichen Planus

Rx

Dexamethasone ( Decadrone ) Elixir 0/5 mg / ml

Sig : 1- For 3 days , rinse with 1 tablespoonful ( 15 ml ) 4 times a day , and swallow , then .

2- for 3 days ,rinse with 1 teaspoonful ( 5 ml ) qid ,and swallow .then

3 – for 3 days ,rinse with one teaspoonful ( 5 ml ) qid and swallow every other time ,then

4 – rinse with one teaspoonful ( 5 ml ) 4 times a day , and expectorate

RxTriamcinolone acetonide ( Kenalog ) 01 %Disp : one tubeSig :Apply to affected area s twice daily as directed

Lichen Planus

Oral Erythema MultiformeAutoimmune , any age , Med reaction ( Pen,Sulfonamide ) Few Patient Herpetic Inf

Occurs Immediately Before the onset of Oral EM

Severe Form Is Called Esvense-johnson Syndrome Or EM Major

� Crusted Lips

� “ Targetoid“ or “ bull's Eye “ Skin Lesions

RxPrednisone tablets 10 mgDisp : 100 tabletsSig : take 6 tablets in the morning until lesions recede , then decrease by 1 tablet on each successive day

Oral Erythema Multiforme ( EM )

+Suppressive Antiviral therapy

Acyclovir tablets 400 mgDisp : 90 tablets

Sig : Take 1 tablet 3 times a day

ChappedOrCracked Lip

Alternate wetting & drying of the vermilion ,resulting in

inflammation & possible secondary infection , Vermilion

Surface is rough & may be ulcerated with crusting . Normal Vertical fissuring may be lost . An Anti-inflammatory agent in

a petrolatum or adhesive base will interrupt the irritating

factors & allow healing .

RxBetamethasoneValerate Ointment 0/1%Disp : 15 gram TubeSig : Apply to the lips after each meal and at bed time

GingivalEnlargementPhenytoin Sodium ( Dilantin ) Calcium Channel Blockers ( Nifedipine &

Others ) & Cyclosporine Are Predisposing drugs ( Folic acid depletion

Check every 6 Months ) . + Blood dyscrasias & hereditary Fibromatosis

Should be Ruled Out By History & Lab tests .

Treatment : Including Plaque Control GingivoplastyFolic Acid Oral Rinse

RxFolic Acid Oral Rinse 1 mg / mlDisp : 500 mlSig : Rinse with 1 teaspoonful for 2 minutes, 2 times a day , and spit out.

Burning Mouth Syndrome

No Clinical SignsMultiple Conditions ( Neurogenic , Vascular , Psychogenic(Xerostomia ,Candidosis , Referred Pain From The Tongue Musculature , Chronic

Infection , Reflux Of Gastric acid , Use Of Medication , Blood dyscrasia ,Nutritional

deficiency ,Hormonal Imbalance , Inflammatory & Allergic Conditions

Rx� Diphenhydramine ( Children's Benadryl ) 12/5 mg / ml ( OTC )

� Disp : 1 bottle� Sig : Rinse with 1 teaspoon for 2 minutes before each meal , and swallow

Work Up :CBC , FBS , Iron feritin , folic acid , B12 ,Thyroid profile

Children's Benadryl is alcohol free

Recipe

� Prescription

� Para clinical Examinations ( Imagings & Labs )

� Referral

� Consultation

� Certification

� Recommendation letter

� Admission letter ( to Hospital )

Certification

Letter( May be extended )

Admission

Letter

Prescription WritingMasoud Yaghmaei Chap 36 (Appendix Peterson 2008 )

Significance of Meds taken by patients in dentistryCommonly Used Meds In OMFS / dentistry

Drug Interactions

A – HeadingB – BodyC - Closing

Parts Of the Prescription

A = Heading

B = Body

C = Closing

Dental infection

Specialty

?

Drugs

1. Prescription2. Over the counter ( OTC )

PDR

Unfortunately , every

drug has more than

One action .1- Desirable = therapeutic effects

2- Undesirable = adverse effects

41 % > 6O Taking Meds

1380-81 ( Shahid Beheshti dental School )

600 patients (25-75 Yo) 38/3 % + Meds If Consider More Than one drug = 56/3 %

NSAIDS , Analgesics , Sedatives, Antibiotics , GI , Cardiac , HBP , Thyroid

Drugs Used In dentistry

& OMFS

� Local Anesthesia ( LA )

� Analgesics

� Sedatives

� Antibiotics

� Corticosteroids

� General Anesthesia ( GA )

+ Emergency drugs

Cartridge : Plain & With Adrenaline & BupivacaineOintment , Spray

IRAN

09646 & 82101� Aspirin 80 , 100 , 325 , 500 Enteric coated 80 & Microcoated 500� Mefenemic acid ( Ponstan ) Cap 250 mg

� Ibuprofen (brufen ) 200 - 400 mg ( 100mg / 5 ml Suspension )� Naproxen 250mg tab , 500 mg Suppository , 500 mg tab delayed release� Acetaminophen 80 , 325 , 500 , ( 120mg / 5ml Sol& Susp & 125,325 mg Suppository )

� Acetaminophen codeine ( 300 + 10 )� Celecoxib ( Celebrex ) Cap 100 , 200 mg� Tramadol Cap & tab ( 50 mg ) , Amp 50mg /ml IM� Piroxicam ( o/5 % Gel , 10mg Cap , 20 mg Supp , 20 mg Amp)

� Diclofenac ( 0/1% phthammic drop, 1% Topical Gel , 50 &100 suppository , 100mg Cap , 25& 50 Tab , 25mg/cc ( Amp 3cc 75 mg )

� Indomethacin Cap 25 mg , tab 75 mg , Suppository 50, 100 mg

� Morphine Sulfate ( MS ) 10 mg / cc Amp� Pethidine 50mg / ml Amp� Pentazocine ( Talwin ) Amp 30 mg

Acetaminophen Inj (Apotel ) 10 mg ml Iv infusion ( 15 min )

500mg eff

Analgesics

�Narcotics

� Opiates ( Morphine,Codeine )

� Synthetics opiatesOxycodone , dihydromorphinone)

� Opiate congeners Meperidine , Methadone , Pentazocine , Propoxyphene

�Non – Narcotics

� Salicylic Acid Derivatives Acetylsalicylic acid

� Salicylamide

� Para-aminophenols� Acetaminophen

� Acetophenetidin ( Phenacetin )

NSAIDS

Analgesics� Narcotics

Continuous dull painGreater Analgesic PotencySedation ( narcosis )

� Non - NarcoticsMild - Moderate Somatic PainNo Sedation ( narcosis )Predominant effects peripheral

NSAIDS� Salicylates ( Aspirin )

� Propionic Acid ( Ibuprofen , Naproxen )

� Acetic Acid ( Indomethacin , Diclofenac )

� Fenemic Acid ( Mefenemic Acid )

� Pyrazolone ( Phenylbutazone )

� Oxicam ( Piroxicam )

� Coxibs ( Celebrex )

NSAIDSInhibits Prostaglandin Synthesis from arachidonic Acid

� Analgesic Peripheral

� Antipyretic Central ( Hypothalamus )

� Anti Inflammatory Peripheral

Stimulus

Phospholipase

Arachidonic Acid Stored in membrane bound phospholipids is released

By Cyclooxygenase ( COX )

Prostaglandin E2 , Leukotrienes C4 & E4

Arachidonic Acid

Prostaglandin

COXEnzymes

Modern Lab Techniques & Biochemical Studies have determined that2 different isoforms of COX exist

COX1 & COX2 Recently COX3

COX 1

� Constitutive ( Continuously Produced by many cell types throughout the body )

� COX 1 Mediated Prostaglandins maintain Homeostasis pathways in the :� GI , Kidney , Heart , Brain ,Vasculature, Airway Function

� Protect GI Mucosal integrity by Stimulation & Production Of Mucus And Bicarbonate , which form a protective barrier against acid Secretion

� In the Kidney Prostaglandins regulate blood flow , renin release , Renal tubular Salt & Water resorbtion , resulting in an increased rate of Glomerular filtration

� In the Circulatory System , Prostaglandins regulate Vascular Homeostasis & Platelet Function

Maintain Homeostasis

COX2 � Induced during the inflammatory process at the site of tissue injury

( Specific to Inflamed tissue & much less gastric irritation )

� Endogenous prostaglandins mediated by COX2 release the inflammatory mediators ( including histamine,bradykinin, leukotriens ,and Substance P ) during tissue trauma

� These Inflammatory mediated events result in increased vasodilation & permeability of the peripheral vasculature , edema , erythema , hyperalgesia , loss of function , and pain

� > Risk of Heart attack , thrombosis & Stroke through a relative increase in thromboxane . Refecoxib ( Brand Vioxx ) Was taken off the market in 2004 because of these Concerns . Some other COX 2 Selective NSAIDs , such as Celecoxib & etoricoxib , are still on the market .

COXCOXCOXCOX1 1 1 1 & COX& COX& COX& COX2 2 2 2 Are Expressed in airway cells , Are Expressed in airway cells , Are Expressed in airway cells , Are Expressed in airway cells , where their activities influence functions such where their activities influence functions such where their activities influence functions such where their activities influence functions such as airway hyper reactivity . Clinical data show as airway hyper reactivity . Clinical data show as airway hyper reactivity . Clinical data show as airway hyper reactivity . Clinical data show

that mixed COXthat mixed COXthat mixed COXthat mixed COX1 1 1 1 / COX/ COX/ COX/ COX2 2 2 2 inhibitors such as inhibitors such as inhibitors such as inhibitors such as Aspirin ,but not COXAspirin ,but not COXAspirin ,but not COXAspirin ,but not COX2 2 2 2 Selective inhibitors Selective inhibitors Selective inhibitors Selective inhibitors

Such as Such as Such as Such as CelecoxibCelecoxibCelecoxibCelecoxib( Celebrex ) , Induce ( Celebrex ) , Induce ( Celebrex ) , Induce ( Celebrex ) , Induce BronchoconstrictionBronchoconstrictionBronchoconstrictionBronchoconstriction and Asthma in sensitive and Asthma in sensitive and Asthma in sensitive and Asthma in sensitive

individuals . individuals . individuals . individuals .

NSAIDsPossess many advantages , including

Analgesia , Anti inflammatory , And

Antipyretic effect , And Unlike Opiods , do

not result in :

Sedation

Respiratory depression

Interfere with bowel & Bladder Function

Recommended Preoperative NSAIDs

Protocol for Postoperative pain Control

� Ibuprofen ( 400 mg ) 30 Min before the initiation of treatment benefits :1. Delayed Onset Of Postoperative Pain2. Decreased severity Of Postoperative Pain

� Precautions :1. Contraindication ( Allergy , Asthma , GI Ulceration , Bleeding disorders , Renal disease ,

Hepatic disease , Pregnant or lactating females )2. Doses Of Ibuprofen in Excess of 400 mg associated with greater incidence of unwanted

side effects & have not been demonstrated to increase Analgesic efficacy

3. NSAIDS May diminish the antihypertensive effect of 3 classes of agents, including the ACE inhibitors , β blockers , and diuretics by inhibition of prostaglandin ( at least after 7 - 8 days ) So their Use should be limited to 4 days in patients taking Antihypertensives

Diuretics , β adrenergic antagonists , Calcium channel antagonistsACE( angiotensin-converting enzyme inhibitors , α-adrenergic antagonism

Direct acting vasodilators )

Gelofen 200-400Advifen 200-400

Ibuprofen ( Brufen ) Tab 400 mg # Ten

Take One q 6 h Prn / Pain

Adult Maximum dose / 24 h 3200 mgPediatric dose 10 mg / kg po q 6-8 h Max dose 40 mg/kg

Gelofen 200-400 mgAdvifen 200-400 mg

Selective COX2 InhibitorCelecoxib ( Celebrex ) Cap 200 mg

# X ( Ten )

Take 400 mg initially then 200 mg q 12 h Prn/Pain

More Expensive

AspirinAnalgesic, Antipyretic , Anti inflammatory +

Uricosoric effect & Antiplatelet aggregation

� Adult 650-1000 mg q 4-6h Max4000

� Children 65 mg / Kg / 24 h divided 4-6 doses

� Infants only few days

� < 13 yrs Possible Reye’ s Syndrome

� Contraindications ( Allergy, Asthma , GI ulcer , Bleeding disorders , Renal &

Hepatic disease , Pregnant or Lactating females )

AvailableRegular

Enteric coatedSustained released

Combination with Antacid ( Buffered tabs)Aspirin + Codein ( Empirin ) Not available in Iran

Analgesics

�Narcotics

� Opiates (Morphine , Codeine )

� Synthetisopiates Oxycodone , dihydromorphinone)

� Opiate congeners Meperidine , Methadone , Pentazocine , Propoxyphene

�Non – Narcotics

� Salicylic Acid Derivatives Acetylsalicylic acid

� Salicylamide

� Para-aminophenols� Acetaminophen

� Acetophenetidin ( Phenacetin )

NSAIDS

Para-Aminophenol

Acetaminophen & Phenacetin� Unlike Aspirin does not impact

Platelet functionGI UpsetUricosuric effectNot Anti inflammatory

� Analgesic & Antipyretic� Severe Hepatic damage (Alcohol abusers ) � Long term Nephrotoxicity ( Papillary Necrosis )

Acetaminophen

Tylenol

� 650 - 1000 mg q 4-6 h Max 4000 / 24h

Iran 325 , 500 , 80 , drops , Syrup , Susp , Suppository

� Acetaminophen with codeine

7/5 mg Tylenol # 1

15 mg Tylenol # 2

30 mg Tylenol # 3

60 mg Tylenol # 4

IN IRANAcetamiphen( 300 )+ 10mg Codeine

Acetaminophen ( Tylenol )The best - selling Over-the-counter antipyretic & Analgesic in the USA

� Similar Antipyretic & Analgesic effect ( Like NSAIDs ) Such as Aspirin & Ibuprofen but lacks Anti inflammatory , Anti platelet , & GI effects

� Generally Supported Hypothesis ( Not literature ) : Acetaminophen act Centrally & Weak Inhibitor of COX1 / COX2

� The discovery of COX 3 In Canines seemed to offer a key to unlocking the mechanism of action of Acetaminophen . But the so called COX 3 is just another COX 1 Splice variant

� Many Results Suggest that Acetaminophen Acts against COX2 and not COX 1 Or COX3

The Exact Mechanism of acetaminophen still remains a Mystery

Narcotic Analgesics

� Opiates

Morphine , Codeine ( 1/6 - 1/12 Morphine )

� Synthetic Opiates Oxycodone , dihydromorphinone

� Opiate Congeners Meperidine , Methadone , Pentazocine , Propoxyphene

Potent analgesicAddiction

Respiratory depressionSedationEmesis

Constipation

Recent Classification Of Opioids

Based on Special receptor bindingmu , Kappa , deltamu , Kappa , deltamu , Kappa , deltamu , Kappa , delta

1. Agonist (Stimulate mu + Kappa ) Morphine , Codeine

2. Antagonist (bind receptors but not stimulate them ( Narcan )

3. Agonist - Antagonist ( Pentazocine Kappa Agonist & mu

Antagonist )

4. Others ( Tramadol Weak mu agonist + Inhibits Serotonin &

Norepinephrine reuptake , Minimal abuse potential &

Respiratory depression , For dentistry equal to codeine )

Opioid Adverse Side Effects � Respiratory depression� Nausea & Vomiting � Mental Clouding� Sedation� Euphoria

� Constipation� Hypotension� Urinary Retention� Pruritus

IRAN

09646 & 82101� Aspirin 80 , 100 , 325 , 500 Enteric coated 80 & Microcoated 500� Mefenemic acid ( Ponstan ) Cap 250 mg

� Ibuprofen (brufen ) 200 - 400 mg ( 100mg / 5 ml Suspension )� Naproxen 250mg tab , 500 mg Suppository , 500 mg tab delayed release� Acetaminophen 80 , 325 , 500 , ( 120mg / 5ml Sol& Susp & 125,325 mg Suppository )

� Acetaminophen codeine ( 300 + 10 )� Celecoxib ( Celebrex ) Cap 100 , 200 mg� Tramadol Cap & tab ( 50 mg ) , Amp 50mg /ml IM� Piroxicam ( o/5 % Gel , 10mg Cap , 20 mg Supp , 20 mg Amp)

� Diclofenac ( 0/1% phthammic drop, 1% Topical Gel , 50 &100 suppository , 100mg Cap , 25& 50 Tab , 25mg/cc ( Amp 3cc 75 mg )

� Indomethacin Cap 25 mg , tab 75 mg , Suppository 50, 100 mg

� Morphine Sulfate ( MS ) 10 mg / cc Amp� Pethidine 50mg / ml Amp� Pentazocine ( Talwin ) Amp 30 mg

Acetaminophen Inj (Apotel ) 10 mg ml Iv infusion ( 15 min )

500mg eff

ImagingsLabs

Paraclinical Examination

Para clinicChapter 33

� Imaging (X-ray, Tomography , CT,

MRI, Sonography , Arthrography ,

Bone Scan…)

� Laboratory Exam.

Chapter 33

43 tests

CBC , Coagulation tests , FBS & HA1c , Ca , P , Alkakine phosphatase

LFT,s , KFT,s , HIV , HBs Ag , Urinalysis

Indications� Hx ( History )

� PE ( Physical Exam )

� GA ( General Anesthesia )

Dentists Need to know

Reading the reports

Check up ( Patient & Family ) lab tests

For our practice

Careful Interpretation

Based on

Hx , PE ,…

CBC� Hgb ( Hb ) 14-18 gm / 100 ml ( 12-16 )

� Hct 40-52 % ( 37-47 )

� Rbc 4/5 - 6/2 million / cc ( 4/5-5/5 )

� Smear Shape & Size

� Wbc & Diff 5000 - 10000

� Pc 150000 - 40000 < 60000 Critical

� Mcv 82-92 Cubic microne

� Mch 27-32 micro micro gram

� Mchc 32 -38 gm /100 ml

Hb x 3 = Hct

RBC x 3 =Hb

Rbc x 9 = Hct

Smear Report

� Normocytic 80 - 96µm3

� Macrocytic >96µm3

� Microcytic < 80µm3

� Normochromic

� Hyperchromic

� Hypochromic

� Anisocytosis (abnoral sizes of Rbc Inc Macro& Microcytic)

� Poikilocytosis abnormal shapes such as :

Burr cells , Target cells , Sickle cells , Nucleated Red cells

Reticulocyte count ( % )

About 1% of the Circulating Erythrocyte mass is

generated by the bone marrow each day . Precursors

of RBCs are Reticulocyte , which account for 1% of

total Red Cell Count

� 0 /8 - 2/5 Male

� 0 /8 - 4/1 Fem

� Reticulocytosis ( Bleeding , Hemolysis , +

Respond to Anemia Treatment )

� Reticulocytopenia ( transfusion , aplastic A)

� Ret Index = Patient Hct / Normal Hct x Ret Count

( % ) Should be 1 if < 1 no good response to Anemia

tx even with high Ret count

AnemiaHb < 12g/dl in W & < 13 g/dl in M

Type ?

MCV , MCH , MCHC +

Reticulocyte Count < 1 % inadequate RBC Production in the bone marrow

< WBC & < Pc Generalized bone marrow defect

Many Signs & Symptoms ( Acute / Chronic )

Fatigue , Palpitation , Shortness of breath , Abdominal pain , Bone pain , tingling of fingers & Toes , Muscular Weakness , Jaundice , pallor , cracking , splitting and spooning of the

fingernails , increased size of the liver & Spleen , Lymphadenopathy , Blood in the stool , Premature graying of

hair and yellowing of the skin ( due to jaundice )

Sore or Painful Tongue ( Glossitis )

Smooth tongue , Redness of the tongue

Angular Chelitis

Some Patients Complain of loss Of taste Sensation

Anemia( Classification by Size & Shape Of RBC )

Normocytic MCV

80 - 100µm3Microcytic MCV

< 80µm3

Macrocytic

( Megaloblastic )

MCV > 100µm3

Sickle cell Anemia

Hemolytic Anemia

G6PD deficiency

Aplastic Anemia

Renal Failure

Anemia of Chronic disease

Iron deficiency Anemia

Thalassemias

Lead poisoning

Pernicious Anemia(B12) )

Folate deficiency )

Hypothyroidism

WBC & Differential (diff)

5000 – 10000

> 10000 Leukocytosis

< 4000 Leukopenia

WBC diff

� Neutrophil 50 – 70 %

� Lymphocyte 20 - 40 %

� Monocyte 0 - 7 %

� Eosinophil 0 - 5 %

� Basophil 0 - 1 %

Shift to the left

Band cells or Stab

( Acute Bacterial Infection & Bleeding )

Hemoglobin Electrophoresis

Normal Findings

� Hb A1 95 – 98 %

� Hb A2 2 - 3 %

� Hb F 08 - 2 % ( newborn 50-80%) Thalassemia Major

CHD , Chronic hypoxia

� Hb S 0 % Sickle Cell Anemia

� Hb C 0 % American Negro ,

HC disease & Sickle Cell

HA1c( Glycosylation Of Hemoglobin A )

Is an electrophoretically fast moving hemoglobin

Reflect Glucose levels over 6 - 12 Weeks

Up to 100-120 days

Normal Level 4 - 6 %

Well controlled Diabetes < 7 %

Hemoglobinopathy

� Hb F > 3 years > 2 % Abnormal ( chronic

hypoxia Such as CHD )

� Hb F Thalassemia Trait & major ( Cooley,s Anemia )

� Hb S Sickle Cell Anemia & Trait

ESR ( Sedimentation Rate )

Sed Rate

Wintrope 065mm(M),o-15(F)

Westergeen O-15mm(M),0-20(F)

Non specific in tissue & Organ damage (inflammatory , Infection , degenerative ,Trauma , Tumors )

Usefull in progress of inflammatory autoimmune diseases

Such as Temporal artritis ( giant cell artritis,Polymyalgia,RA )

Osteomyelitis Respond to Treatment

Coagulation

Tests�Screening

�Specific

Screening

� PT ( second , % , INR )

� PTT ( 25 - 40 seconds )

� PC (150000 - 400000 ) < 60000 critical

� BT ( 1- 4 min )

� Fibrinogen ( Factor 1 ) ( 200 - 400 mg/100 )

Specific

� Coumadin > PT

� Heparin > PTT

� ASA > BT , PTT

� ITP, DIC < PC

� Hemophilia > PTT, F8 assay

� Liver dysf > PT + < PC + > BT

� Malaborption Syndrome (antibiotics) > PT

� Hemodialysis > PTT + < PC + > BT

� Chronic Leukemia < PC + > BT

Warfarin , Coumarin , Coumadin , Dicumarol

2-7-9-10 Vit K dependent

PTTAPTT = 25 - 40 seconds

PTT = 60 - 70 Seconds

Anticoagulation therapy 1/5-2/5 Normal

Intrinsic ( 8 , 9 , 11 , 12 ) +

Common ( 1 , 2 , 5 , 10 )

Pathways

Factors 1 , 2 , 5 , 8 , 9 , 10 , 11 , 12

PT

Extrinsic ( 7 ) + Common

Pathways ( 1 , 2 , 5 , 10 )

Anticoagulation Therapy 1/5 - 3 Normal

Factors

1 , 2 , 5 , 7 , 10

PT

� Second 11-15 1/5 Safe

� % 70-100 = / > 30 %

� INR < = 1 2/5

Platelet Count ( PC )

� 150000 - 400000

� < 60000 (50000) Critical

� < 10000 Severe Bleeding

Thrombasthenia

� Congenial ( Von willebrand)

� Drugs (ASA , Plavix ) 7-10 days

� Diseases (Cirrhosis,Uremia, Pernicious Anemia , LE ..)

PTCA

Percutaneous

transluminal

coronary

angioplasty

Bleeding Time

� Duke 1- 4 Minute

� Ivy < 4

Hemophilia

F8 Def

> 3 %

1 -3 %

< 3 %

0/05 x 70000 x%30= 1050 Units

q 12 -24 h +

EACA 100mg / Kg q 6h/10days

Bleeding

Remember 5 As1. Aspirin

2. Anticoagulants ( Coumadin & Heparin )

3. Antibiotics ( Malabsorption Syndrome )

4. Alcohol

5. Anticancerous ( Chemotherapy )

Ca , P ,

Alkaline Phosphatase( ALP1 In Liver & ALP2 In Bone )

Giant Cell Granuloma & Hyperparathyroidism ( Brown Tumor )

Ca 8/5 - 10/5 mg /100 ml

Phosphor 2/5 - 4/5 mg / 100 ml

Alkaline phosphatase 1-4/5 Unit ( Bodansky) 4 -13 ( Armestrang )

< 2 years 85-235 ImU /ml

2 - 8 years 65 - 210 Imu / ml

9-15 Years 60 - 300 Imu /ml

16 21 years 30 - 200 Imu / ml

Bone Scan

TC 99Hot Spots

Tmj

Bones ( Tumors ,Osteomyelitis )

Cholesterol (150 - 300 mg / 100)

Ideal < 200

HDL 30-80

LDL 70-190

Less than 1/3 of Cholesterol

Is In HDL

Total Cholestrol < 200 & LDL < 100 & HDL >60 ( is Ideal )

High Cholestrol + High LDL + Low HDL + HBP + Smoking ( High Risk for CAHD )

Triglyceride ( VLDL)

40 – 150 mg / 100

Triglycerides >150 is a separate risk Factor

High level usually + Low HDL

Lipoproteins

4 Types

� HDL ( alpha LP )

� LDL ( beta or s,0-20)

� VLDL ( prebeta or s,20-400 ) Triglycerides

� Chylomicrons

10 Indexes to

IHD1. Age

2. Hyperlipidemia ( LDL,VLDL) & Low HDL

3. Cigarette Smoking

4. Hypertension

5. Obesity

6. Diabetes

7. Physical Inactivity

8. Hyperuricemia ( Uric acid > 6/9 mg/100 )

9. + Family Hx of IHD , DM , Hyperlipidemia ..)

10. EKG abnormality

HDL Higher

In Women

Estrogen>HDL

Androgen < HDL

FBS ( NPO / 8 h )

65-110 mg /100 ml

> 126 mg = diabetes ( 1997

ADA Criteria for

Diagnosis )

GTT / 3h > 200 ( Urine + )

Glycohemoglubin ( glycosylated hemoglobin )

HbA1c

Reflect Glucose levels in blood over

the 6 - 12 weeks

100 - 120 days

Normal 4 - 6 %

In well Controlled DM < 7 %

No NPO

Uric Acid

3-8 mg / 100

Renal Function

� BUN 10-20 mg / dl

� Creatinine (Cr) 0/7 - 1/4 mg / dl

� Creatinine clearance (Ccr) 85-140 ml /min

� Urinalysis ( First Void if Specific gravity 1/016 or greater & PH 5/8

Or less & No Glucose & Protein Most likely Kidney Function is WNL

BUN > 30-50 Moderate > 50 / 60 Severe Not Specific

Creatine > 2&3 Moderate > 6 Severe RF

Creatine Clearance 10-50 Moderate < 10 Severe

Thyroid Function Tests

� PBI

� BEI

� T3

� T4

� TSH

Pancreatic Function Tests

Vital organ in Homeostasis

Amylase Not specific

Lipase More Specific

Tripsin Most specific

Acute MI

� SGOT ( serum glutamate Oxaloacetate transaminase )

� LDH ( Lactic dehydrogenase 5 Isoenzymes LDH 1 & 2 )

� CPK ( MB In Myocardium , MM In Muscle , BB In brain )

� Troponin T

� Troponin I Acute MI

Prehospital Phase Management by dentist

Hospital Management by Cardiologist

CPK

� MM (Muscle)

� MB (Myocard)

� BB (Brain)

LDH

Isoenzymes 1-5

specific 1 -2

HIV � ELISA 6 -10 Wks Post Exposure +

� Antigen P24 ( New ) + 2 wks post Exposure

� CD4 Tcell count (600-1600 Normal) < 600

Immune def Needs Antibiotics

Serum Osmolarity

275 - 295 mosm

SIADH

D Insipidus

Serum Electroytes

� NA 135-145 meq /L

� K 3/2 -5/5 meq /L

� Cl 95 -105 meq /L

� Mg 1/5 -2 meq /L

� Ca 8/5 -10/5 mg /100

� P 3 -/5 mg /100

ABGs (arterial blood gases)

� PH 7/35 – 7/45

� PCO2 35-45 mm/hg

� HCO3 22-26 meq /L

� CCP 55-75 ml co2 /100cc

� Bass Excess O ± 2 meq /L

� PO2 80 – 100mm / hg

� O2 Saturation 95-98%

LFT,S

� SGOT

� SGPT

� Alk Phosphatase

� Bilirobin

� PT

� BSP

� Serum Albumin

Bilirubin

� Total 0/2 – 1/2mg /100

� Direct ( Conjugated ) < 0/3 mg / dl

� Indirect ( Unconjugated ) O/1 – 1 mg / dl

� Non Icteric Subclinical Hepatitis ( TB < 3 )

HBSAG

� Carrier HB ( + HBSAG )

� Persistent HB ( + HBSAG & + LFT,S )

� Active HB ( As above & + Biopsy)

Acid Phosphatase

Prostate CA Metastase to bone

Serum Amylase

� Pancreas

� Salivary Glands

� Intestinal Obstruction

� Upper GI Surgery

Gram Stain

Culture ( A & Anaerobe)&

Sensitivity (antibiograme)

Actinomycosis

C & S

Urinalysis

� Physical (Vol,Col,SG ,Smell,Trasp)

� Chemical ( PH,Protein,glucose,Hgb,….)

� Microscopic (RBC,WBC,Epith,Casts)

Urinalysis

� Volume

� Color

� Transp , cloudy

� Smell

� Sp gravity

� PH

� Protein

� Glucose

� Ketone

� Hgb

� Billirubin

� Bens jones protein

� RBC , WBC

� Epith cells

� Casts & Crystas

PSA ( Prostate - Specific antigen )

0 – 4 ng /ml

> 10 ? CA

Stool Examination for

Occult blood

( Stool for OB )

CSF

� Opening Pressure (100-200mm /H20 )

� Color , Appearance

� Glucose ( ½ Serum 45-80 mg /100 )

� Protein ( 15-45 mg/100 )

� Cell count ( WBC , RBC) up to 5 all lymphocytes

� CSF leake ( ß 2 Transferrin )

Medication Levels

Digoxin 1/3-1/7 ng/ml > 2/4

Carbamazpin 2-8 ug/ml > 12

Chloramphencol 10 - 20 ug/ml > 25

Propranolol 30-100 ug/ml > 150

Xylocaine 0/5-2 ug/ml > 5

Drugs Used In dentistry

& OMFS

� Local Anesthesia ( LA )

� Analgesics

� Sedatives

� Antibiotics

� Corticosteroids

� General Anesthesia ( GA )

+ Emergency Drugs

Hand book of Local Anesthesia

Fifth Edition 2004 Mosby

Antibiotics

� Pen VK

� Pen G

� Procaine Pen

� Benzatine Pen G ( 6-3-3 )

� Ampicillin

� Amoxicillin

� Co Amoxicillin

� Gemtamycin

� Metronidazole

� Clindamycine

� Erythromycine

� Cephalosporines ( 1st , 2nd , 3rd , 4 th Generation )

Post Op Infection ?

ATS 90%

GF 10 %

Adverse Reactions

� Allergy

� GI Side Effects N / V

� Superinfection ( Candida , AAC = PMC )

� Blood dyscrasia

� Interestitial Nephritis

� Drug Fever

� Neurotoxic

� Drug Interaction

� Resistance

� Etc

PenicillinG

Acid Labile ( Only IV Or IM )

G+C & Rods+ Most Anaerobes

HL 30 Min ( healthy Kidney )

2 - 3 MU q 2-4 h ( HL × 4 )

Aqueous Crystaline Pen G

Pen G ( Na 100mg /1mu Or K 65mg or 1/7 Meq )

Possible Hyperkalemia

Procaine Pen G ( 400000 & 800000 )

( Only IM )

Peak 1 - 2 h last 24 h

800000 U Q 12 h

Benzathine Pen G

Only IM

Last 3 - 4 Weeks

1200000 U

Penicillin 6.3.3

Benzathine Pen G 600000

Procaine Pen G 300000

Potassium Pen G 300000

Pen VK

Acid Stable ( 65 %

absorbed VS Pen G 30 %

absorption )

Peak Serum 30 Min

Up to 4 h detectable

500 mg po q 4 - 6 h

Penicillinase - Resistant Penicillins

� Methicillin ( Acid labile ) IM & IV Less Used

� Cloxacillin Oral

� Dicloxacillin Oral

� Oxacillin Oral , IM , IV

� Nafcillin Oral , IM , IV

Extended Spectrum Penicillins

Wider Or Broader Spectrum penicillins

Extension G-Rods Not Penicillinase

1. Ampicillin - like agents ( Ampicillin , Amoxicillin )

2. Carbenicillin - like agents

Combination Of Extended

Spectrum Penicillins & β

Lactamase inhibitors

Amoxicillin + Clavulanic Acid

Co Amoxiclav Cap 625 mg ( 500 +125 )

Cap 375 mg ( 250 + 125 )

Powder 312 mg ( 250 + 62/5 )

Penicillin family

� Pen G , Pen Procaine , Benzatine , PenVK

� Penicillinase Resistant Penicillins

� Extended Spectrum Penicillins ( Ampicilline &

Amoxicillin )

� Combination of Extended Spectrum penicillins & β

Lactamase inhibitors ( Co Amoxiclav )

Adverse Reactions To Pens

� Allergy 3-5 % Population & 10 % Previously received ( Simple Skin rash to lethal anaphylaxis ) Anaphylaxis in 0/02 % ( 10 % may be fatal )

� GI side Effects ( N/V , diarrhea ) dose related

� Super infection ( Thrush , PMC = AAC )

� Interstitial Nephritis

� Blood dyscrasia

� Drug Fever

CephalosporinesNew Generations for G New Generations for G New Generations for G New Generations for G ---- RodsRodsRodsRods

� First G : G + C ( Except Enterococus&Staph Resist To Methicillin ) + E Coli +

Klebcilla , P . Mirabilis + Anaerobes :

Caphalotin ( Keflin )

Cefazoline ( Ancef )

Cephalexin ( Keflex )

� Second G : > Spectrum against G - & Anaerobes Amp Cefamandole Oral

Cefaclor ( Ceclor & Ceftin ) Cefoxitin ( B.Fragilis In OMFS )

� Third G : > Spectrum Enteric G - & Nosocomial Inf But Less effective Against G

+ C ( Cefotaxime , Cefdinir , Cefixime ….)

� Fourth G : Cefepime

Erythromycin

� 2 - 5 % Urinary Excretion Mainly Via Bile

� Allergy to Pen

� Macrolid ( Erythromycin ,Azithromycin ,Clarythromycin ,Dirithromycin)

� Spectrum like pen

� Bacteriostatic

� Main disadvantage Rapid Few Step Resistance

( Penicillin Slow Stepwise Resistance )

( Streptomycin Single Step )

Clindamycin

� Severe Odontogenic Inf ( Anaerobe Resistant to Pen )

� Good Oral absorption ( Even + Food )

� Oral & Amp ( Cap 150 mg , Inj 150mg / ml )

� Good Bone Penetration ( Osteomyelitis )

� No CSF penetration (even Inflammation slight BBB)

� Liver Metabolism & Then Urinary Excretion

� Main Complication PMC = AAC & blood dyscrasia

� BE Prophylaxis ( Pen allergy ) 600 mg po 1h pre op

PMC = AAC

� Superinfection

� Overgrowth ( Clostridium dificile = Toxin )

� Severe diarrhea ( 20% With antibiotics 10 % Usual

Intestinal Flora changes But 10 % AAC

� Serious Problem

� Treatment Vancomycin ,Metronidazole

Tetracyclines

� Very Limited in Odontogenic Infection Unless Resistant to Pen & Erythromycin ( C& S )

� In Refractory Periodontitis ( Juvenile P )

� Good Oral Absorption ( Unless Chelation with Al , Fe , Ca , Mg

� Containdicated in pregnancy & Children < 12

� Good Bone Penetration

� Doxycycline ( Cap & tab 50 - 100 mg Amp100-200 Syr 50mg / 5ml

Chloramphenicol

� Typhoid Specific

� 3 % more Effective in Odontogenic Infection ( Compare with pen ) but not used routinely Since is highly toxic ( Bone Morrow depression )

� For Severe Odontogenic infection Invades Brain & Periorbital ( Meningitis , Brain abcess , Cavernous Sinus thrombosis )

� Check CBC routinely

� Amp 1 gm

Metronidazole

Flagyl

� 1962 for Vincent infection & Tricomonasis

� Used for parasitic infection

� Now Used for anaerobes ( Obligate )

� Never Use as a Single drug

� Good BBB penetration

� Good Oral absorption

� 2 Major Complications ( Convulsion , Disulfiram )

� Tab 250 mg q 8 h & IV 500 mg vial

Aminoglycosides

Almost no anaerobic effect

Aerobe Gram - Rods

Never for odontogenic infection Unless C&S ( Enteric Flora )

Gentamycin=Garamycin

Kana , Strep , Tobra , Neomycin

New Beta - Lactam AntibioticsCarbapenams , Monobactams , Quinolons

� Carbapenems ( Imipenam ) Most Broad Spectrum is Available today . Only for Gram Negative Infection ( Urinary , pulmonary , Abdominal

� No Oral absorption Only for injection

� Not Used for odontogenic infection unless ( C&S)

� Monobactams Spectrum like Aminoglycosides (Aerobe G -Rods )

� Quinolons ( Ciprofloxacin )